Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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299 Treating the Worn Dentition with Steve Cutbirth : Dentistry Uncensored with Howard Farran

299 Treating the Worn Dentition with Steve Cutbirth : Dentistry Uncensored with Howard Farran

1/25/2016 3:40:03 PM   |   Comments: 0   |   Views: 990

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AUDIO - DUwHF #299 - Steve Cutbirth

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VIDEO - DuwHF #299 - Steve Cutbirth

When young Steve Cutbirth broke his two front teeth sliding into second base, little did he realize that he would spend his adult life helping others who met similar fates.  The art and science of aesthetic restorative dentistry became his passion, one that has continued to expand during the past quarter-century.


Today, Dr. Cutbirth maintains a full-time practice in Waco, Texas, that is in the top 1% of practices in the country based on production with an overhead of 40%; but he doesn’t stop there. 


As Director of the Center for Aesthetic Restorative Dentistry, Dr. Cutbirth shares his patient-first philosophy and commitment to state-of-the-art excellence with like-minded colleagues. 


Dentists from throughout the nation as well as abroad attend the Advanced Restorative Series, which is a five-weekend course dealing with advanced restorative techniques, differential diagnosis and treatment of facial pain (TMJ), functional/occlusal problems, and practice systems.  Hands-on training and lectures by world-class specialists distinguish the program.


Dr. Cutbirth says the endeavor is his calling, and an outgrowth of the excellent training he had.  “It’s been such a rewarding venture.  The teaching center is set up the way I’ve always wanted advanced dental education for myself.”


Masters’ Courses limited to 12 restorative series alumni, expand the program and provide future teaching faculty.  “I sincerely believe that Dr. Cutbirth wants you to have a life in dentistry uncommon to those comfortable with mediocrity,” says Eddie Pruitt, D.D.S., Houston.  “He has an invaluable base of technical knowledge that he distills and presents to you on a platter.”


Dr. Cutbirth also conducts and annual update/review course on the latest studies and techniques.  Participants, who laud his informal, conversational style, “hold my feet to the fire.  There’s so much knowledge in the group,” Dr. Cutbirth says.  He’s convinced that the “toothache dentistry” mandated by healthcare systems is misguided; patients deserve the time it takes to provide them with a comprehensive examination and treatment options.  Only then can dentist and patient work together to achieve the optimal result.


His mentees concur.  “The techniques, skills and knowledge that I absorbed from Dr. Cutbirth’s courses have completely changed the way I practice dentistry,” says Tien Ngo, D.D.S., Dallas.  “Thank you Dr. Cutbirth and staff, for bringing back the passion for excellent dentistry, which I thought I had lost forever.” 

Howard: It is a huge honor to bring back Dr. Steve Cutbirth. I don't bring many people back, but Steve, I loved your podcast last time and I know you have like 48 million gazillion cases. So, after our last podcast, I wanted to bring you back and have you go over some more complicated cases. Just a bio, in case you missed his first podcast. Dr. Steve Cutbirth, private general dentist practice with focus on complex restorative dentistry in Waco, Texas since 1981. Began and directs the Center for Aesthetic Restorative Dentistry in Dallas, Texas for the past 15 years. The Center teaches 5 to 10 hands on 2-day, Friday-Saturday lecture/laboratory courses for practicing dentists. Each course builds on the previous course. Porcelain veneers, crown and bridge, replacing missing teeth, especially in the aesthetic zone, diagnosis and treatment of myofascial and intra–articular pain and dysfunction, restoring the most complex cases, including severe wear cases, restoring vertical dimension, full and partial denture stabilization with small diameter implants. By the final course, the dentist should be able to confidently treatment plan and restore complex cases in conjunction with appropriate specialists. 

He's been married for 38 years to Sharon, has 2 daughters, Catherine and Caroline, living in Austin and Nashville, two great son-in-laws, an incredible 5 year old granddaughter named Genevieve. 

How are you doing today, Steve?

Steve: Good, Howard. How are you?

Howard: Good. Good. What are you going to teach us today? 

Steve: We're going to talk about increasing vertical [inaudible 00:01:48], we're going to talk about full mouth reconstruction, and then we're going to wander into restoration of a severe wear case. 

Howard: Well, whenever you talk about a full mouth restoration, the first question comes out of their mouth is, can you increase the vertical or what happens if you change the vertical. Dentists are very, very nervous that if they change the vertical, the TMJ's going to go crazy and they're going to be in a world of turmoil. So I hope you cover that when you're going over these complex restorative cases. 

Steve: They'll never be nervous about that again. They'll never be nervous about that again. Ready?

Howard: I'm ready. Rock and roll, buddy.

Steve: Right. I'm going to go through a lecture format as a queue for what we're going to talk about. So, the first thing we're going to talk about is just a basic full mouth reconstruction complex case. Now, remember this is golden rule dentistry. This is not looking for people to put restorations on all their teeth. This is someone who is desiring that or needs that. 

I love that photograph, don't you?

Howard: She's smoking a hundred dollar bill. Oh, she's got a skeleton ...

Steve: Lights her cigarette with a hundred dollar bill. 

Howard: And a skeleton brand.

Steve: So these are the things you've got to think about. See that's what all of our courses build on the other, because if you're not a world expert on occlusion and treatment of intra–articular and myofascial pain problems, and really understand the [inaudible 00:03:29] disc assembly and all those things, you're going to get into a world of hurt. So the first thing we think about, this is not increasing vertical, this is just full mouth reconstructions. The incisal plan, the occlusal plane, centric relation and occlusion, and by the way, if I had to give up everything I know about dentistry, and only be left with one thing, it would be occlusion, and especially centric relation. Centric relation is the beginning point of these complex cases. If you don't have centric relation, you ain't got nothing. We can talk about that later.

We're going to talk about vertical dimension. There's some very famous people in dentistry that have said, never increase vertical dimension. That people don't lose vertical dimension. Unfortunately, that's wrong. I hold these people in the highest esteem, but that's just not right, and I'll show you why that's not right in a minute, and why it's not a problem increasing vertical dimension in appropriate cases. 

All right, so, one of the things we're looking for is do we have enough tooth structure upon which to place a restoration. We gain retention by either increasing vertical so you don't have to remove occlusal incisal tooth structure, endodontics for the internal retention, or periodontal crown lengthening to make the tooth longer, so you've got more retention that way. 

I want to assess crowding. Missing teeth/hopeful teeth. The Dentin/enamel/teeth condition. Stress on the system, are they bruxers or clinchers. Cost, time, patient compliance, hygiene. Once you've done this as long as I've done it, and you've done as many cases as we've done. We're doing these cases every day. You're very thoughtful in beginning, because you understand, especially in the severe [inaudible 00:05:38] cases, Howard, that we're going to talk about later, and I tell patients this, these cases are like restoring a NASCAR. You can have the greatest mechanic in the world restore a NASCAR, but there's going to be maintenance. There's going to be breakdown, and the patient needs to understand that going in.

All right, so now this is just with a full mouth reconstruction. The incisal plane should blend into the occlusal plane. If I've got an inappropriate incisal plane occlusal plane, how am I going to fix that? 

Centric relation and centric occlusion. What's the condition of the disc, because the disc often times, if you have a severe wear case, the disc is going to be in about the same condition that the teeth are in. 

Vertical dimension. Endodontics. These are ways of gaining retention for restorations. Vertical dimension, you just don't have to reduce much incisal occlusal tooth structure. Endodontics, we're gaining retention internally. Or periodontal crown lengthening. Remember, periodontal crown lengthening is not just gingivectemy. The body is going to reestablish the biologic width, which is a gingival line approximately 3 millimeters from the bone level, and so, if you only do gingivectemy, the gingival will grow back and reestablish that 3 millimeter distance. So you've got to remove bone and soft tissue in a case like this. We've done crown lengthening and porcelain veneers. 

Crowding. What do I got to do about that? Can you restore the crowded teeth without orthodontics? Now I'm a big fan of orthodontics, but often times if you're going to restore all the teeth anyway, you can sometimes do that without orthodontics as long as you end up with a healthy result that the patient can clean, it's functional, all those things. 

The condition of the enamel, dentin, and teeth. You don't just jump into this cases. Stress on the system. Cost, time. This should be appropriate dentistry and that's why we spend so much time on the front end visiting with the patient to find out who's connected to the teeth, and why are we doing whatever we do. 

Patient compliance and hygiene. Are they going to take care of it? No matter what you say, at the end of the day, that patient is going to hold you responsible for the restoration. So don't get into something that's not going to stand up. 

All right. So, in a full mouth case, without increasing vertical, phase one is going to be the pre-exam interview, the comprehensive exam, and the wax up, and then the consultation. The interview's just to find out who's connected to the teeth, why are you here. 

The comprehensive exam is just what we say. We don't do anything definitive for a patient, dentally, until we've done a comprehensive exam. The only thing we'll do before comprehensive exam, is get them out of pain, if they've got a toothache or something like that, we'll take care of that, but we don't do any crowns or anything else definitive until we've done a comprehensive exam. I often say, I'm really a home remodeler, and before I remodel somebody's kitchen, I want to analyze the whole house. How's the foundation, how's the walls, I want to talk to the person that's having the kitchen redone, and say, tell me about the rest of the house. Are we going to do anything to the rest of the house? Are we going to knock out any walls? Are we going to change the floor plan? Are we going to redo the wall paper? I want to know those things before I do any definitive work on a patient. 

Then, wax it up. You know exactly what you can do from the wax up. Then, we have a separate, definitive consultation. At that appointment, we talk about the condition of the patient's teeth and what their treatment options are, if they want to proceed with treatment. Remember, it's not just about the patient. It's about you the dentist, because your reputation is on the line with every case we do, as you know, Howard. 

Oral hygiene instruction, prophy or scaling, and root planing. Then, extract the hopeless teeth. Endodontics, if needed. Periodontal crown lengthening. Again, we're creating situations to gain retention on those teeth for the restorations. 

Phase 3, provisionalize and then restore the mandibular anterior teeth, to the second bicuspid or the first molar. Then provisionalize, then restore, the maxillary anterior teeth. We do the front teeth first. You know why? 

Howard: Why?

Steve: It's like the front wheel of a tricycle. Your eccentric should ideally be on the anterior teeth. So you want to work that out first, then you plug in the posterior teeth, and you don't want any eccentric contacts on those teeth. Do you know why that is?

Howard: Tell us. 

Steve: They're close to the big muscles, the master, the medial [inaudible 00:11:55], the [inaudible 00:11:57], all back in the back of the mouth. So that's where most of the pressure comes from. If only the anterior teeth are contacting, that's like trying to crack an egg with your arms extended way in front of you and the egg between your fingertips. There's not much pressure out there. If you want to crack that egg, you're going to bring your hands back close to your body, and press right there, and you'll crush it in a second. So when the patient moves side to side, you want those movements away from the big muscles. If those movements are on the posterior teeth, you're going to put too much pressure on those posterior teeth, you're going to split them, crack them, et cetera. You only want the posterior teeth, especially the molar teeth, to contact when the patient bites straight down. So you work out the eccentric movements on the anterior teeth first. 

Okay, now here are the lower teeth. Now, why do you leave one tooth not prepped? In this case, the second molars. It maintains your vertical dimension, because we're not increasing vertical dimension. So we've restored the mandibular anterior teeth, now we've restored the maxillary anterior teeth, so you can see, I've left the second molars unprepped. Veneers on two bicuspids. 

Then, Phase 4, is provisionalize and restore the maxillary and mandibular molars. Now, if you're doing the molars at the same time, it's very important when you place the provisionals, these are provisionals on the second and first molars, that you place the provisionals, and then you roughen the occlusal surface of the lower molar provisionals, squirt on some [inaudible 00:13:49] acrelate, place microfilm on the maxillary provisionals on the molar teeth, and have the patient close together hard. Squeeze hard into that unset [inaudible 00:14:03] acrylite. Let that set up, mark it with a pencil, mark the stops with a pencil, remove all the wings, and leave those stops. That way you know those teeth are not going to super erupt between the prep phase and the seat prep phase. Then, seat the molar crowns, and you can either use gold occlusal or [inaudible 00:14:30] is really good. 

Then, night guard, 3 month recall, and oral hygiene instruction. 

Okay, now let's switch to what we came to talk about today, restoring the severe wear case. Don't forget, these cases are like restoring a NASCAR. It's very important that you spend time on the front end with the patient. Not only in conversation, but in writing, talking about the maintenance. I really don't worry about litigation, I worry about relationships. I don't want somebody getting into something that they don't know what they're getting into. That's why we write this out and have them sign it, and read it to them, just so they know that they have a big problem, and I don't want their big problem to become my big problem. 

So, these are the check points for restoring a severe wear case. The main points, again, are centric relation, and remember, that's where you start. I know there's some groups that question centric relation. No, name one joint in the body in which the condyle is not supposed to be maximally seated in the fossa when that joint is under stress, Howard. Can you name one?

Howard: Tell us.

Steve: There is none. When you're running on your knee, don't you want that condyle to be seated maximally in the fossa, when you're running on that knee? Well the only time occlusion makes a difference, is when the person's squeezing together. When that happens, you want that condyle to be seated maximally in the fossa. We can talk about that on another cast if you want to. 

The incisal edge position. Well, I published an article on this a couple years ago, on the lip position versus incisal plane. You've got three types of lips. The flat lip, the moderately arched lip, and the maximally arched lip. Now, you can only use the flat lip to help determine incisal plane. We used to say, remember in dental school we said, you want 2 millimeters of incisal edge displayed when the lip's in repose. You remember that?

Howard: Mm-hmm (affirmative).

Steve: That's crazy. If you've got somebody ... I can show you a presentation I make on lip position and with a maximally arched lip, when the person just lets her lip go in repose, she displays the whole tooth. A moderately arched lip, they're going to display half a tooth with lips in repose. So the only time you can use the upper lip as a guide for incisal edge position of the maxillary anterior teeth, is if it's a flat lip. Most men have flat lips in repose. We can talk about that another time. The average central is 11 millimeters. You really don't want a central incisor more than 12 millimeters long, especially if someone has a high lip line. 

The occlusal plane. It should blend seamlessly into the incisal plane, with no step between the cuspids and the bicuspids. We must have adequate thickness, occlusally, for restorations. Now remember the thickness in the anterior is different that the thickness in the posterior, because the anterior teeth don't contact incisal edge to incisal edge. So, how are you going to get that, then? Well, as we said, the only way you're going to get retentions for restorations in a severe wear case, is either, you can get it by increasing vertical dimension and not have to reduce occlusal tooth structure, and you can get it be periodontal crown lengthening, and have more tooth structure [inaudible 00:19:02] to retain the restoration, or you can do it endodontically and have internal retention. 

Adequate freeway space. When the patient puts their lips together lightly, just put your lips together lightly, Howard, and then hum. Just hmmm. 

Howard: Hmmm.

Steve: When you do that, the teeth should not touch. Not people say you should have 2 to 3 millimeters between the teeth when you do that. The main thing is, you don't want the teeth to touch when you lightly touch your teeth together and hum. Then the teeth length. 11 millimeters is ideal for the central. It's about 11 millimeters for the cuspids. About 9 millimeters for the lateral incisions. About 9 millimeters for the lower incisor teeth. So you've got to have all that in the mental computer when you're putting this together. 

I'll always appreciate knowing centric relation, because as long as I know the back is centric relations. The fronts, the incisal edge position and the vertical dimension. As long as I've got those things, then we're just filling in the rest of it. If you understand [inaudible 00:20:12], but you've got to get the front and the back first. So centric relation sets the back. 

Then the incisal edge position. Now, this gentleman has a flat lip in repose. You'll notice here, there's no tooth display, so it looks like he's got no teeth. When we were finished restoring him, he had tooth display. So that's a significant thing. With a flat lip patient, it's easy to determine incisal edge position. You want some tooth display with lips in repose. 

You also want the incisal plane to be parallel to the lower lip, the upper lip, and the pupillary line, and if the patient has a high lip lien when they smile, the gingival line. You always want the maxillary center incisors to be the longest teeth and you want a line drawn from the incisal edge of the cuspid tooth to the incisal edge of the other cuspid tooth, to mirror the lower lip or look like a banana or a quarter moon, and then you want that to blend seamlessly into the occlusal plane, just like a horseshoe. Now, if somebody does not have a high lip line, you don't have to worry as much about gingival line. I think we talked a little bit about gingival line last time, just touched on it. 

Then you want adequate space for the occlusal thickness of restorations. Look at this case. This individual's wife had passed away and we may look at his case today, and he just looked scary. It had been about 5 years before, and he said, I'd like to date again. Well what are you going to do with that case, Howard?

Howard: I [crosstalk 00:22:12].

Steve: Do you take out the teeth and put in dentures? Can you imagine what that'd be like, with somebody grinds like that?

Howard: Or he just had to move from Dallas to Kansas and date women there. That's where I'm from. That's looking at half my family.

Steve: But you're a good looking guy. What's that like? Are you like Joe Nameth? Remember Joe Nameth? Remember what he said?

Howard: The pantyhose commercial quarterback from the Jets? 

Steve: Yeah. Yeah. You remember what he said? 

Howard: What?

Steve: That he set his alarm clock a little earlier every day because he couldn't wait to get up in the morning and look at himself in the mirror because he got better looking every day. Is that you?

All right, now look at this. How are you going to restore that if you don't increase vertical dimension? How you going to restore that? If we have a chance, I'll show you the first case back in the early 80's that I restored by increasing vertical dimension. I just re-read the book of one of my favorite people in dentistry that said, never increase vertical dimension, and his teeth were just about like this. If you remind me, Mr. Downing, I may show you that case. I restored his son a few years later, who ran a mine in Tennessee or Kentucky, and his teeth were just like his dad's. So you look at that, if you remove a millimeter or two of the occlusal, what are you going to put the restoration on? 

So, the ways we have of gaining room for restoration, through either increasing vertical dimension, periodontal crown lengthening, or internal retention from endodontics. That's all we've got, and in a lot of these cases, taking out the teeth and putting in dentures, even with implants, is not a good idea because lateral forces on implants are not good.

So when we get to the end, we want adequate freeway space. You remember that one. Put your lips together, hmmm. Teeth should not touch. Ideally you'd like 2 to 3 millimeters between the teeth when you hum. 

Teeth length. You need to know these lengths so you can plug it into the mental computer when you're analyzing these cases. The average maxillary central incisor is 11 millimeters, 10 and a half to 11. Lateral incisor, 9, 7 millimeters wide. The average central is 8 and a half millimeters wide. The average cuspid is 11 and it's about 8 millimeters wide. Average lower incisor is about 9 millimeters long. One and a half lower incisors equals an upper incisor. 

All right, so these are some secondary points with increasing vertical dimension full mouth reconstruction. You can mount these cases on an articulator, with a face [inaudible 00:25:32], which you should do. You can even do a [inaudible 00:25:36] path, but in the end, you're going to have to work out the envelope of function in the patient's mouth. These cases are never completed at the appointment that you seat the restorations. Now you remember, envelope of function is any movement of the mandible. So, I often say that some people chew like an alligator. Chomp chomp. Other people chew like a cow. So it's like a ... It depends on if you're a helicopter coming in for a landing or an airplane or a duck landing on water. If they come in like this, they're going to bump that tooth, even if your centric relation occlusion is ideal. So you've got to spend some time working out envelope of function. 

The gingival lien, remember, should parallel the incisal edge of the maxillary teeth, the lower lip, the upper lip, and the pupillary line. If someone has a low lip line, you don't have to worry, most of the time, about gingival line. If they've got a high lip line, you've got to consider that before you begin the restoration. 

The alert feeding position is a critical consideration that many people overlook. That means that when you're through placing all the restorations on the teeth, and you sit the patient straight up in a chair and lightly put your hand on their chin and have them tap together, you don't want the 4 incisor teeth to contact. The mandible comes forward about a half a millimeter in that positions, so you want to be sure you can pull [inaudible 00:27:29] between the maxillary incisor teeth when the person's in the alert feeding position. Otherwise, they'll bump those teeth every time they close their teeth together when they're sitting upright or standing upright. You want the contact, in these cases, to primarily be between the cuspids and the [inaudible 00:27:53] of the first molar. You want to be absolutely sure that the first contact, are that the second molars and the distal of the first molar, as well as the 4 incisor teeth, do not contact in CRO before the cuspids, the first and second bicuspid, and the measial of the first molar. That's critical. 

Centric relation occlusion, very important. Now, remember, the only time the teeth should ever touch, is when the patient swallows, and then just very lightly. When you chew your food, your teeth shouldn't touch. Then grinding and bruxing is a parafunctional habit. That shouldn't occur. So the only time teeth should really touch, is when you swallow, and then, very lightly. 

Facial features following restoration. Let's consider them. 

Eccentric occlusal contacts. You know, you don't want any balancing side contacts. You want the eccentric contacts on the anterior teeth, possibly the first and second bicuspid, if the cuspid's compromised. The only time you want it on the molar teeth is if they have an anterior open bite. Now remember what we talked about with the big muscles of closing. The master and [inaudible 00:29:14] and temporalis. If you contact on those teeth in eccentric contacts, you put too much pressure on those teeth, and on the system in general. The only time you want the molar teeth to contact is when the patient bites straight down.

Speech is easy. Speech was a mysterious thing to me back in the old days. If you go by the fundamentals of incisal edge position, in 34 years of practice, I've never gotten into trouble with speech, but you've got to communicate it correctly. If you're changing the incisal plane of a patient significantly, say they're severely worn, you're changing the read of a woodwind instrument. It's like changing your grip with a golf swing. It's going to feel different, but if you follow these principles, i.e, the lower incisal plane should be flat, the maxillary incisal plane should form a u mirroring the lower lip, the central incisors should be the longest teeth, about 11 millimeters long, no longer than 12, the incisal plane should blend seamlessly into the occlusal plane, and then the pupillary line, the gingival line, the upper lip, the lower lip, and the incisal plane of the upper and lower anterior teeth should be approximately parallel. If you do that, you've created the perfect reed for the woodwind instrument. 

You've got to give the patient confidence when you do this, though. Have you ever heard it said that if you tell someone ahead of time, if you explain something to someone ahead of time it's a reason. If you explain it after the fact it's an excuse. So, before you start, you tell the patient, your speech is going to be different for 2 days. 2 days only. Then it's going to be better than it ever was. Once you receive the provisional restorations, what I want you to do, is as soon as you go home and your numbness has worn off, stand in front of a mirror and read aloud for 30 minutes, twice a day, for 2 days. Then you will love your speech pattern. If you don't tell them that, though, they're going to be confused, because these years, they've adapted a speech pattern for saying F, S, V, Church, and Swish, based on an inappropriate reed in the woodwind instrument. 

You know, when you say F, F, F, the incisal edge touches the [inaudible 00:32:14] border, F, at the end of the sound. When you say B, the incisal edge touches the [inaudible 00:32:21] border of the lower lip at the beginning of the sound, B. Then S, Church, and Swish, is passing air between the incisal edges of the maxillary and mandibular incisor teeth. So you've created a perfect reed for that woodwind instrument. They've just got to get used to is, and that takes exactly 2 days. When you see them again in a week, they'll come back, and they'll say, Howard, just like you said, that first day I thought, oh my gosh. By the end of the second day, I had it. You've got to explain that before you start.

Now, most of the full mouth reconstruction cases I do in severe wear cases, have a disc that's just trashed and most of the time, the condyl is flat. I'll bet I've got the largest collection of MRI's of TMJ's, possibly in the world, and the key, in my opinion, to restoring a patient with no disc is centric relation, CRO. If they've got a slide and they squeeze their teeth together, they're going to constantly be moving this condyl up and down in the fossa, down the [inaudible 00:33:46]. If you're in centric relation occlusion, so that when you squeeze the condyles seated, you're not going to be rubbing the condyl bone to bone on the [inaudible 00:33:56], and these people will have no problem, no pain, intra-articularly. It's a good idea to have an MRI, I think, before you start these cases, if the teeth are severely worn. 

So these are considerations before we restore a severely worn [inaudible 00:34:23]. Are the incisal edges displayed? Now, remember, this only counts in flat lips, when the lips are in repose. Is there enough vertical space to restore the teeth? Has the patient lost vertical dimension? Have they lost vertical dimension? You've got to consider the ratio between the anterior and posterior teeth, regarding vertical dimension increase. So you can't just randomly increase vertical dimension and say, okay, I'm going to increase them 6 millimeters in the anterior. That won't work, because you've got to fill that in with porcelain, and half of it's got to be on the incisal edge of the mandibular anterior teeth, so you don't want to fulcrum 3 millimeters of porcelain off of the incisal edge of lower anterior teeth. How do I know that, Howard? 

Howard: How?

Steve: See this, can you see my gray hair and receding hairline? That's not from dying my hair gray and shaving it back. I tried it, back in the day, when I didn't really know how to do this. Vertical dimension mush be increased on the hinged arc of centric relation, and when the lips are lightly touching, the restored teeth should not contact. 

Okay, so considerations, prior to increasing it. This is it. This picture tells it all. You can see the foreground, but you can't really see what's down there. Consider the age of the patient. If somebody is 30 years old, and they've severely worn their teeth, you've got a long time to maintain those teeth. You better be sure that the patient understands it's their problem. They've got to be convinced that you are a world expert in restoring these cases, but no matter how good you are, just like in NASCAR, there is going to breakdown, there is going to be maintenance. I actually published a good article to read on this, I published in PPAD probably 10 years ago, and it talks about that. Where somebody's 80 or 75 it's not as big a deal, because it doesn't have to last that long. If somebody's 30, though, there will be maintenance. There will be maintenance if they're 60 or 70, unless they've stopped bruxing. 

Okay, so, when this lady presented, she did not have appropriate tooth display with lips in repose. There was no tooth display at all. So, here, we have restored her, and there is proper tooth display with lips in repose. 

Is there enough vertical dimension space to restore the teeth? No. So, remember, we've go 3 options. Increase vertical dimension, so we do not have to remove occlusal tooth structure. The second option, if we remove tooth structure to restore this severely worn case, look at how little tooth structure will be left. So we'll have to either crown lengthen the teeth or perform endodontics and gain internal retention. I would never do that in a severely worn case. I might do it in combination, but I wouldn't cut the tooth down so that there's only a millimeter or two of tooth remaining. 

Now, you're a great question, Howard, that tells me that you are a student of the literature. There are some very good people that have written never increase vertical dimension. You've read that. 

Howard: Absolutely.

Steve: Okay. Has this person lost vertical dimension? The reason why, is that the patient does not lose vertical dimension, that the ocular process grows with the teeth as they wear. Correct? That was the premise. It was a great premise, but unfortunate, it is wrong. Here's how you know someone has lost vertical dimension. They have thin lips, they have down turned corners of the mouth, they have horizontal lines in the face, the nose is closer to the chin. They look like granny gump. There's no tooth display with lips in response, with a flat lip, and the teeth are severely worn. Would anybody look at this gentlemen and say, he hasn't lost vertical dimension? 

Howard: I think everyone would say he lost vertical dimension. 

Steve: Yeah. So, Mr. Downing changed my life back in the early 80's. I thought I was going to kill him, because I hadn't worked out my current system for increasing it. I do not increase vertical casually. I don't increase it causally, but I'll say this. Of all the patients, the hundreds of patients I've restored, increasing vertical dimension, do you know how many have ever had an issue with it? Guess.

Howard: How many?

Steve: Zero. 

Howard: So why do you think everybody fears it? Why is it just ... 

Steve: I don't understand it. I don't understand why they fear it. You ever made a denture? 

Howard: Of course. 

Steve: You think you change the vertical when you make a denture?

Howard: Oh, absolutely. 

Steve: So, it's just something ... I mean, I don't want to be critical, because it scared the hell out of me when I did it the first time on Mr. Downing. I took 6 months to restore that case, just thinking I was going to kill him because of the literature. You don't want to be cavalier about it, but in my practice, I have to increase vertical dimension to restore these cases. Look at this. Look at this, right here. How am I going to do it? See, when you increase vertical, look at what it does for you. You can create an appropriate incisal plane and occlusal plane. If you tried to restore this person right here with this roller coaster incisal plane occlusal plane, how are you going to make the planes right? Remind me to come back to that. We can ponder that great [inaudible 00:41:03]. 

The bottom line is, this is super bowl dentistry. This is really complicated. I think everybody needs to understand it, even if they don't want to do it themselves, because there's lots of conversation that goes into this, with the patient. You know, when you get into these, you're kind of putting yourself in harm's way, because the potential of breakdown is a lot greater than with putting a crown on a tooth. The thing that took me years to figure out, was how much do you increase vertical if you are going to increase vertical? Do you know the answer to that?

Howard: No.

Steve: You increase it no more than a millimeter and a half between the second molar teeth, because that translates into 3 to 4 millimeter increase between the anterior teeth. Now the issue is, you've got the lower anterior teeth. You've got to split that increased vertical dimension between the anterior teeth between the maxillary anterior teeth and the lower anterior teeth. Now, stay with me on this, this is is very technical. Are you with me to that point? 

Howard: Absolutely. 

Steve: You've got to take that extra space and you've got to split it between the upper anterior teeth and the lower anterior teeth. Now, the upper anterior teeth, where is that space going to be taken up on the palletal? The lower anterior teeth contact the maxillary anterior teeth on the palletal. Not on the incisal edge of the maxillary anterior teeth. You with me?

Howard: Mm-hmm (affirmative).

Steve: The lower anterior teeth, though, where is that space going to be taken up? On the incisal edge. So as the studies show, in just a regular patient, you don't want to [inaudible 00:43:07] porcelain off the incisal edge of an anterior tooth more than 4 millimeters max. If it's lower anterior teeth in a severe wear patient, you really don't want to [inaudible 00:43:23] more than 2 millimeters off the incisal edge. So that's your limiting factor. You can increase up to a millimeter and a half between the second molars, but anteriorly, you don't want to increase more than 3 to 4 millimeters, if you want the case to hold up. 

Now, how much do you increase the incisal edge of the maxillary incisor teeth? If it's a flat lip, you want some tooth display with lips in repose. If it's a moderately or maximally arched lip, you want a 10 to 11 millimeter tooth. In a lower tooth, you want 8 and a half to 9 millimeters. So, that's how you determine it. The key point here is, the three to one ratio, you do not increase the vertical dimension more than a millimeter and a half between the second molar teeth. Let's go through this. 

So when you increase it, you increase it on the hinged arc of centric relation. When the lips are lightly touching, remember, when you get to the end, the restored teeth must not contact. Say hmmmm, and the teeth shouldn't touch. So these are the steps for restoring severely worn teeth. This took me about 15, 20 years to figure out. 

Now, as we talked last time, I like to do things simply. I'm really not interested in having the Steve Cutbirth instrument for increasing vertical dimension. Once I figured out that one and a half between the seconds and about 3 to 4 between the anterior teeth was the measurement, I looked around the top of the counter in the auditory, and I wanted to find something that was about 3 and a half millimeters. Well, the end of a cotton tip applicator is perfect. That's what that is. If you torque it down, the cotton part, down toward the chin just a little bit, that's a little over 3 millimeters. So that's how much I want to increase vertical. 

Then, I take an occlusal registration record at that increased vertical, and wax it up. Now you cannot mount the case in CO on an articulator as they present, and increase the vertical on the articular, without an ocular registration record and wax it up. If you do that, only the second molar teeth will contact when you go to the mouth. You've got to take the occlusal registration record at the increased vertical dimension you are going to build the case to, and mount it at that with that record. Then, this is what you're going to get in the mouth and you won't be hitting just on the second molars. 

So I thought, how can I do this? How can I transfer this to the mouth and use it and maintain my predetermined vertical dimension increased? I thought, okay, the last teeth I'm going to be restoring are the molar teeth. Remember our full mouth reconstruction, lower anterior, upper anterior, lower posterior, upper posterior? So I said, what if I put composites on the occlusal surface of the molar teeth and the increased vertical. So I roughen these teeth and etch them, place microfilm on the lower teeth, place unset composite on the upper molar teeth, place my cotton tip applicator between the anterior teeth, and very gently, and have my assistant, pull that cotton ball from this end of the stick, down just a little toward their chin, and have the patient lightly close into the composite, and then set it with a curing light. These are the centric stops. Get rid of the wings, and that's your working vertical. 

So this is my working vertical right now. What's holding that vertical dimension? The stops on the molar teeth, right? 

Howard: Right.

Steve: They were set at an increased vertical. So now, I've got to get through this, I've got to prep this upper lower anterior teeth before the patient leaves the office that day, otherwise they're only hitting on the molar teeth. 

This is a note. When increasing vertical dimension, all the teeth in at least one arch must be restored. All the teeth in at least one arch must be restored. I recommend restoring all the teeth in both arches. The lower incisors and cuspids may be restored with the porcelain veneers. All the maxillary teeth and the bicuspids and molars must be restored with full crowns. Now the reason I like to restore them all, is because if you've got a severely worn detention, you're going to have some very inappropriate incisal planes and occlusal planes. This lets you create ideal incisal and occlusal planes. 

All right, so. Are you staying with me on this? 

Howard: Of course. 

Steve: What have we done so far? We've increased the vertical dimension approximately 3 to 3 and a half millimeters in the anterior with the cotton tip applicator, and we've placed the composite on the upper molar teeth at that vertical dimension, set the composite so now our centric stops and centric relation occlusion are on those molar teeth at an increased vertical dimension of about 3 millimeters in the anterior. We're going to prepare and fabricate provisional for the upper and lower anterior teeth. Now remember, all the upper teeth must be restored with full crowns. The lower teeth, from the bicuspids posteriorally, must be restored with full crowns. The anterior teeth, from cuspid to cuspid, may be restored with porcelain veneers. So these are my provisionals for the upper anterior teeth. These teeth, these provisionals, do not contact the lower anterior teeth before the ... The lower anterior teeth have not been prepared. So these provisionals do not contact the lower anterior teeth. I've taken half of this vertical space, for these maxillary provisionals. I'm going to use the other have of the incisal occlusal space for the lower anterior provisionals. Does that make sense?

Howard: Yeah, you're splitting the space.

Steve: I'm splitting the space. Now what I'm telling you in an hour, it took me 20 years to figure out. So now we've got upper and lower prepped. Now once you've completed the preps, the preps should be parallel to the pupilary line. The incisal plane of the preps should be parallel to the pupilary line unless you've got some previously shortened teeth on one side. You don't want to cut this tooth back too much if, say, they ground off this side and this tooth wasn't the ideal length. If you can, for the sake of your technician, you want this incisal plane of the upper and lower anterior teeth to be parallel to the pupilary line, which is parallel to the table top. So if they were working on the model, not on the articulator, they know that it's flat. 

Okay, so this distance should be about 3 and a half, 4 millimeters, which was attained by increasing the vertical dimension between the second molars a millimeter and a half. Provisionals for the lower anterior teeth. I'm going to impress the lower anterior teeth. Remember we talked about this before. When you're restoring doing a full mouth reconstruction, you restore lower anterior teeth, upper anterior teeth, then lower posterior teeth and upper posterior teeth. So I'm going to impress the lower anterior teeth. I'm going build those lower restorations against the upper provisionals. Now why don't I impress the lower interior teeth and the upper anterior teeth right here at the same time? Why not? Too much. You've got too many floating pieces. You're losing so much of your guides for your laboratory. It's just, what's the hurry? Get it right as you go. So take an extra appointment. 

Then we're going to seat the lower anterior crowns and veneers against the upper provisionals. Now what's on the second molars? Remember? Composite stops. It's holding vertical. Now, these cuspid teeth and bicuspid teeth are going to contact the upper ... They're going to contact from cuspid all the way back to the second molar. Remember, in the alert feeding position, you want to be able to pull shim stock between the upper lateral and central incisors. You don't want these teeth to contact at the same time the posterior teeth are contacting, because they may be in a little bit of premature contact, and that can cause a significant inter articular problem, if you have premature anterior contact on the incisor teeth. So be sure you can pull shim stock through the teeth when the patient bites down between the maxillary anterior, centrals, and lateral incisors, when the patient bites down firmly on the posterior teeth. 

Then you can modify the upper preps, anterior preps, bicuspid preps, as needed. Then, impress the upper anterior teeth from bicuspid back. So remember, these are full crowns. Then seat the upper anterior bicuspid crowns and an anterior night guard. Now, as we talked about, I want the contacts to be from cuspid back to the mesial of the first molar, and I want to be able to pull shim stock between the upper, central, and lateral incisors, as well as the second molars and the distal of the first molars. 

Howard: Steve, do you ever use any technology of that, like that T scan made by technology Scan? Or do you think shim stock is okay for ... This is a very complex full mouth rehabilitation. 

Steve: I like things I can see. It's like a wax up versus a computer image situation. I like things I can see and I can get my hands on. I know this will work. I know this works, because I've got my hands on it, and it's so simple. You can use all those gadgets. I love technology, but I'm not a gadget guy. 

Howard: Okay, what about with your lab? Will you mount this on a semi adjustable articular with a face bow? 

Steve: Right. Right, right. 

Howard: Is your lab a local person?

Steve: No. 

Howard: Do they need photos? 

Steve: Yes. We email photos. Here's the key point that took me about 20 years to figure out. When you get through, and the patient bites down hard, you want the contacts and centric relation occlusion to be on cuspid through mesial of first molar. You want to be able to pull shim stock, which is one half of one one thousandth of an inch, when they bite down hard, between the anterior central incisors and lateral incisors, and the second molars and the distal of the first molar. Critical, critical. 

Okay. Notice how all the eccentric movements are on the anterior teeth. Remember we talked about that. You don't want any eccentric movements on the posterior teeth, unless they have an anterior open bite. If they have an anterior open bite, you want it on the most anterior tooth. That takes pressure off the system. When only the anterior teeth are contacting, 85% of the muscle fibers of the medial teragoyd and temporalis and the master muscles shut down. So you've only got about 10-15% of the muscle fibers firing when just the anterior teeth contact. When you're chewing food and biting straight down, you want all the muscle fibers firing. So you want those molar teeth to contact, but in anterior, when they're eccentrics, you want the minimum. All right, then you prepare and impress the upper and lower molar teeth. 

Now remember we about these molar provisionals. You roughen the occlusal surface of the lower molar provisionals with a course diamond football burr. Then you squirt bisacrylyte on the surface, microfilm the surface of the maxillary molar provisional teeth, these are provisionals, then have the patient bite down hard and grind in eccentric movements. You then come back and remove the wings, after you've marked the centric stops, and that'll keep these teeth from super erupting, so you can do upper and lower crowns on the molar teeth at the same time. 

Then seat the upper and lower crowns. Now, since I did this case, we've got [inaudible 00:57:58], you can use them. It's hard to beat gold on occlusal surfaces of molar teeth if aesthetics is not an issue. Some of these teeth, these cases, I say I'm building a bomb shelter.

Then you want another night guard. Now you don't want a football mouth guard night guard. You want a hard acrylic, flat plane, centric relation occlusion night guard. If the patient can tolerate it, I'll build one for the upper and lower teeth. We're going to school the patient in what makes this hold up, because they've already signed the pre-treatment explanation sheet of what's going to happen to this case as time goes on. So they've got a vested interest in not breaking these crowns. They wear their night guard every night. Both of them, and they understand that these are not like a set of tires that wear out. They're like porcelain plate. I tell them I have my grandmother's china from 1910. We've got every place setting, because we've never dropped it on the floor. Now if you go one night, and you've been out carousing, and you come back and you say, I'm not going to wear my night guard, and you grind like a bad boy, you can break some of these porcelain crowns, because porcelain is like a china plate. Now with Emax and things like that, the bruxer, you and I talked about that last time, you remember that conversation?

Howard: Yep.

Steve: What do you want to break? If you put a crown on a tooth that cannot break, something's going to give if the patient bites on it hard enough. Either the tooth is going to loosen ... I can show you cases that that's happened. Or the tooth itself is going to break. So, of the things that could happen, I personally, would rather for the cement to give way or the crown to break than the tooth the break or the root to break or the tooth to loosen. That's why with porcelain veneers, I want a cement that's a little bit, that's not quite a strong as the porcelain or the tooth, because I'd like the cement to give way before the tooth breaks or the veneer breaks. 

Now, with this night guard, do you notice, only the cuspid teeth contact. Can you imagine why that is? Muscles. When only the anterior teeth contact, 85% of the master and medial teragoyd and temporalis muscle fibers shut down. They do not fire. So when this patient is grinding at night, he's putting less stress on the system. You want to be sure to tell them to not wear that more than 8 hours, 10, because if they wore it all the time, the posterior teeth would super erupt. This is just for nighttime wear. 

See, this is pre op, no tooth display with lips in repose. When someone says, how much do you want? Some is the answer. It's not a number, it's some. Coinciding with a central incisor that's about 10 and a half to 11 millimeters long. No more than 12. 

Lips in repose. Okay. That's it. 

Howard: That was amazing, buddy. That was just amazing.

Steve: We've got a million of them.

Howard: Well, I'm trying to expose you to these guys, because I love the fact that you've been doing this basically since 1979. Dallas is only 2 hours away from anywhere in America, and these kids need guidance and you're the man to do it. I know you've got a gazillion cases. I also wish you would create some online C courses on dental town, because I know [crosstalk 01:02:17]

Steve: Here's what we'll do. Here's what we'll od. 

Howard: Those are a lot of separate people in there, because a lot of people take the online CE, because they also want continuing education credit. 

Steve: You want to see something interesting? You got time to see it?

Howard: Yeah, what is it?

Steve: This is the first case I ever did back in 19 about 81, and I've actually published this in dentistry today. This was a patient of mine and he wanted to have his teeth fixed, and I'd read the articles on, and I've studied different [inaudible 01:03:02], that said never increase vertical dimension. Well, what are you going to do? What are you going to do? This is primitive. This is a primitive form of what we're doing right now. I said, I've got to do it, and I thought I'd probably kill him. I knew where I wanted to go, but I didn't know exactly how to get there. So I just started, and the first thing I did was grown lengthening and endodontics on the lower teeth. Now he's missing the 4 maxillary anterior teeth. These are slides. I didn't know how to increase vertical, so I just put a permanent night guard on the posterior teeth, hoping ... I hadn't worked out the 1 and a half to 3 and a half to 4 thing yet. So I knew I wanted to increase him just enough to get restorations on those teeth. I made him wear this for 6 months, locked in up here, because I thought, I'm probably going to kill him. He's probably going to die. Then, I started cutting that off, and did the lower anterior teeth. We've got ... 

Howard: You mean locked in, so for 6 months he couldn't take it out? 

Steve: No. It was locked into the upper teeth. He could squirt in between here. Use a water pic and a proxy brush to get in between there, but I thought, well, if these people are saying you can't increase vertical, they didn't say what happened, but I thought, probably death. I was about 26 or 7 back then. 

So look at this anterior guidance. I mean, I worked that out to the 9's on those provisionals, and then would have him wear those for 2 or 3 weeks. Then I slowly am adding provisionals and working out those eccentrics so carefully. [inaudible 01:04:55] endo on all those teeth and crown lengthening. Don't try this at home, by the way. All we had was porcelain to metal, so I put ... 

Howard: Did you do the crown lengthening yourself?

Steve: Oh yeah, oh yeah. We'll talk about that. Next time we'll do one on getting the lines right. 

So I put each of these on individually and used zap it to connect the framework, and then pulled it ... Remember plastigum?

Howard: Yep. 

Steve: Pulled it with plastigum, soldered it. Here we go, then did the posterior teeth. I mean I worked this out, it took me forever, and there's the final on the anterior teeth, here's the posterior, here we go. All the eccentrics on the anterior teeth, built a bomb shelter in the back. Now, at the end of his life, he lived another 30 years. You know what happened to this? He chipped one of these teeth, one of the maxillary interior teeth. I won't go into his son right now, but his son came to see us years later, and he had a situation just like his dad's. 

Okay, what else.

Howard: Well, I think we should wrap this up because it's a hour 10. The brand is about a hour long on the podcast, and that's what they;'re used to, and if we want to do more, I think we can do more podcasts, but I really think that this would best be done with Howard Goldstein on the continuing education, the online CE. I think you and bow could make, I mean, God, you guys could do a 2 hour to 20 hour lecture on this stuff. 

Steve: If you spent a day in our practice, you would die. This is Waco, Texas, a hundred thousand people, and I see somebody from 8 to 2 o'clock every day. From all over the country. People are dying for somebody that's trained in this kind of work, but you got to pay a certain price to learn how to do it. You're not going to get it in 1 weekend CE course. I'm waiting to see some dentists that want to step up and learn how to do this, and not think they're going to use a, I mean, do a podcast, and learn how to manipulate an eccentric, and how to prep teeth, and how to take proper impressions and provisionals. I mean, this is a process, if you get into this complex stuff, Howard. I'm afraid people will think they can do it, and they really can't. It is righteous. I'm open to conversation, but it's like an interview or a consultation with a patient. I'm just not knowing where dentistry in general is right now. You'd know more of that then I. That's why I'm interested in you and I sitting down sometime, and just going through what's what. 

Howard: Well, we will do that. I just sent you and Howard Goldstein a text. I think we should wrap this up, because that's the brand.

Steve: Good. Yeah. 

Howard: Talk to Hogo, and you, me, and Hogo will figure out what we're going to do next. 

Steve: Good. 

Howard: All right, buddy. Thank you so much for another case, and I hope you're cheering for the Arizona Cardinals to beat the Green Bay Packers today.

Steve: You know I'm going to, just because of you. You going to cheer for the Cowboys this afternoon? Oh, wait. 

Howard: Poor Tony Romo. 

Steve: You know, if I was that guy and I broke my collar bone twice in the same year, I think I'd be saying ... Remember Don [inaudible 01:09:03] thing, he turn out the lights, party's over. I think I'd would have had enough. 

Howard: Yeah. I know, that's a sad ending. It's something that dentists don't realize, that we make so much more money because we can have a 40 year career. A lot of these fancy NBA, NFL players only have 3 and a half years. 

Steve: I'll tell you what, this kind of practice is so much fun. 

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