Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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381 Controversies in Cosmetic Dentistry with 5 Friends from Around the World : Dentistry Uncensored with Howard Farran

381 Controversies in Cosmetic Dentistry with 5 Friends from Around the World : Dentistry Uncensored with Howard Farran

5/1/2016 12:41:35 PM   |   Comments: 0   |   Views: 398

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Dr. Mykhayluk graduated from Ivano-Frankivsk Dental Academy (Ukraine) in 2008. He specialises in micro dentistry, mostly indirect restorations, and practices at his family practice, Dental Clinic of Mykhaylyuk - Oral Design Center in the Ukraine. Dr. Mykhayluk is official trainer of Carl Zeiss Dental Academy, DSD lecturer and Co-founder of MicroVision Group. Dr. Nuno Sousa Dias from Porto, Portugal graduated from Tel Aviv University and lectures internationally. Mark qualified from the University of Witwatersrand in 1981. He then spent 23 happy years in private practice in London before ` seeing the light` and returning to Cape Town. He was a member of the British Academy of Aesthetic Dentistry, the American Equilibration Society, and a Fellow of the International Congress of Implantologists, is a registered ITI speaker and has been involved in numerous international Study Groups. On his return to Cape Town he was approached to start the South African Academy of Aesthetic Dentistry (www.saaad.co.za), of which he is now President. Dr. Stavros Pelekanos received his undergraduate degree in Dentistry (D.D.S.) in 1991 from the National and Kapodistrian University of Athens, Greece. In 1993, he obtained his doctoral degree in Prosthodontics (Dr med dent) from the University of Freiburg (Prof. Dr. J.R. Strub), Germany. Following his professional training, Dr. Pelekanos established a private practice in Athens, oriented towards prosthodontics, implantology and esthetic dentistry. In 2002, he was appointed full-time Lecturer at the Department of Prosthodontics, Dental School, University of Athens, Greece, and is now Assistant Professor in the same department. Since 2013 Dr. Pelekanos is an active member of the European Academy of Esthetic Dentistry (EAED). His professional affiliations include also: the International College of Prosthodontics (ICP), European Prosthodontic Association (EPA) and Greek Prosthodontic Association. He is a faculty member of gIDE Institute (Global Institute of Dental Education, Los Angeles, California). In 2008 and 2011, Dr. Pelekanos received second and first prize at the scientific award competition of the European Academy of Esthetic Dentistry held in Madrid, Spain and Istanbul, Turkey respectively. To date he has published over twenty articles, two chapters in books and lectures nationally and internationally.

Howard:

It is a huge honor for me ... Sorry, I lost my voice. I've been lecturing today [at South Africa 00:11], to be podcast interviewing the man, Dr. Naz, from the Ukraine. You have exploded all over dentistry. I see you lecturing in Saudi Arabia, all over. It's cosmetic dentistry, minimally invasive, microscope. Tell us why everyone around the world wants to hear Dr. Naz.

 

Naz:

First of all, thank you for the good words. Actually, yeah, really, the last 4 or 5 years, I've been to 42 countries.

 

Howard:

42 countries.

 

Naz:

Yeah, 42, so traveling a lot all the time. I've been several times to the States, lecturing. What are we trying to do, like the new stuff? We're trying to use microinvasive dentistry in our daily practice, not to make it too special, but just to make it like a routine work, like using magnification, the microscopes the loupes in the daily practice. Not showing that it's some fashionable stuff, but this is actually equipment that simplifies our daily life. This is the point.

 

 

Of course, when you're using the proper equipment, when you're doing the proper protocols, you raise the quality of your clinical cases. To prove that it works, we actually document everything. This is what we show people and this is what people like, because people don't like just when somebody is showing off. They like when the dentists are showing the cases that are repeatable in their daily practice.

 

 

This is why they come to our courses. They look at how we work. They try it at home; it works in their homes. Then they come back again to learn more and more and more. This is how it spreads all over the world.

 

Howard:

You're a big proponent of magnification?

 

Naz:

Yes.

 

Howard:

Do you wear loupes? Do use a microscope? What do you [use mostly 01:50]?

 

Naz:

Actually, I'm using the microscope for the last 7 years. I've never used loupes. Basically, some procedures that people typically tried in with the loupes, I never even tried because I just never had them. I started with a microscope, and, to be honest, I don't regret because, first of all, it's really comfortable for me as a clinician because I don't have back pain, I can work full days, I can work the whole week. I'm not going home [soring 02:18] with my pain in the back. I'm enjoying my work. It's like doing a habit and getting paid for doing the habit. This is the point.

 

 

This is the one side of the microscope usage and another side is you actually, of course, raise the quality of the treatment, because you see the tooth that is 22 times bigger. You open a whole new world in dentistry for yourself. Even for the person who's doing dentistry for the last 20, 30 years, it's like something totally new. It's like a fresh breath in your profession.

 

Howard:

What microscope do you use? What brand name?

 

Naz:

I'm using ZEISS. It's from Carl Zeiss Company, Zeiss [pico 02:53].

 

Howard:

German?

 

Naz:

Yeah.

 

Howard:

You use the magnification of 22X?

 

Naz:

22 is like maximum magnification. The average one that I'm using is 10, 12 usually. With the 22, we'd check the final precision, all the restorations. We check the fit of the restorations, we check the final details of the margin, and all the other stuff, because you know how we say, "Less you see, better you sleep," but we realize that ...

 

 

I had some doctors coming over to me after the course and they were saying, "Nazariy, maybe it's too late for me to use the microscope. Probably I will not use it, but I will tell you for sure if needed a treatment, I will come to you." People believe in this. This is the most important.

 

Howard:

Would you roll it into the operatory, or do you mount it on the ceiling, or is it behind you at 12:00?

 

Naz:

Actually, now I would advise that you can mount it on the ceiling so, in this case, you save space. Actually, I have mine moving around. Why? Because when we got the first one in the clinic, we thought that maybe we will share it with the other doctors. If somebody has difficult clinical cases, we'll give them the microscope. Believe me, once you start using the microscope, you're not sharing it. It's just yours, and you're going to fight for it.

 

Howard:

Would you agree that right now, in 2016 ... Probably 83% of the guys you're talking to are Americans and the other 17% are from a hundred and, what, 42 countries? When they think of a microscope, it's usually an endodontist. You're not using this just for root canals. You're using this for-

 

Naz:

What I would like to say to my colleagues that, first of all, don't be afraid of the microscope because this is not a tool that complicates your life. This is a tool that simplifies it. This is the first rule.

 

 

Another rule is the microscope is not endodontic tool. The microscope is actually a magnification ... I don't know. You can put your signature on a check with a microscope, if you want. This is just the tool that lets you see all the details much better. This is the point. You can basically use it for the direct, indirect, for whatever. We always give a very simple example.

 

 

Take the best hygienist that you have in the USA and ask him to do a hygiene as professional as he or she can do it. After that, take the microscope and check it. Believe me, the person will be really disappointed because she will see how many things you could have missed, but not because you're a bad professional or something, but because you have some limits of the vision. This is the point. With the microscope, you're breaking the limits. You can do everything in a really good [lab 05:31].

 

Howard:

You're a prosthodontist?

 

Naz:

Yes.

 

Howard:

What do you mean when you say that you're focused on microinvasive cases and aesthetic upgrades?

 

Naz:

It's actually what I like the most, to do ultrathin veneers. We are doing many clinical cases when we don't practice at all. We have additional veneers with a thickness of 0.1, 0.2 millimeters. Because my father is a dental technician, he is an Oral Design member, and he's doing veneers really, really ultrathin.

 

 

If I'm using the microscope in my daily practice, it's very important that my dental technician is also using the microscope in his technical lab because, otherwise, it will turn out just like my hobby, because I will do a precise preparations, but the final restorations will not be so precise, and I will be disappointed. This is why you must work as a team with your dental technician. You are using a microscope in magnification and he is also using it.

 

 

I know that, for example, American people are always looking for the things to simplify their work. When they hear about microscope the first time, it might be scary, like, "Oh, my God. It's going to take a long time." I agree with you. At the beginning, yes, but after, you'll be like, "I don't know how I was work without it all the time," because after that, you will do all the procedures much faster and with way better quality. This is the point. You will never regret it, believe me.

 

Howard:

In America, in the 30 years I've been a dentist, 30 years ago, it was all lab. Then it's hard making a big swing towards CAD/CAM. Some people think that it's all going digital and some people think it's going towards back, lab. Your process, you do really high end cases, when you do ultrathin veneers, are you doing these with CAD/CAM, or are you doing these at lab? What are your thoughts on CAD/CAM?

 

Naz:

My position is ... And not only mine, but many guys who are doing really nice quality work in the world, that nowadays if you want to have a top level of dentistry, it's handmade. Of course, all the dentistry is moving to the side of digital world, and I agree. I'm sure that in the near future, I will be using a lot more of the scanners, I will you use a lot more of the CAD/CAM machines.

 

 

Once you have a good connection with a dental technician and a good clinician, then you will have a really great final results, because the veneers, 0.1, they're not just milled or something, they are being layered. In 0.1 millimeter, you might have already different stains, you might have different ceramics, and different visual effects. This is the point. This cannot be done with the machine. Only human that sees the teeth, that sees the color can actually accomplish this kind of treatment.

 

Howard:

I agree. When you're doing high end cosmetic cases, are you ever unraveling some of these teeth with ortho or Invisalign or clear retainers? Are you doing more traditional with veneers?

 

Naz:

Actually, right now you're saying very proper things because when we speak about minimally invasive dentistry, it's really good to combine orthodontic treatment with the indirect restorations to the ultrathin veneers. Of course, I can accomplish the case without ortho, but, in that case, I need to practice way more, as you realize.

 

 

My philosophy is to treat people the way how I would like to treat myself. For myself, I would like to go for ortho, if possible, course, if there are no limits about this. Then I'd go ahead and do veneers, if we are speaking right now about a steady cases and stuff like this.

 

 

Of course not all the people agree for the ortho, because some people will say, "We want to have results now. We don't want to wait 2 years." It's also their choice. We cannot say that that treatment is incorrect. This is also correct treatment, but, of course, it's way better if we add ortho.

 

Howard:

You've lectured in 42 countries, which is amazing. That is amazing. Some countries in the Middle East, in the United States, want just toilet bowl, kitchen sink white. Other countries like more natural. I wish you would list the countries that want toilet bowl, kitchen sink, porcelain white and which ones think, "Oh, that's too American," because a lot of people say that that's only Hollywood. Only Americans like that bleach white. I talked to a lot of dentists, and I'm going to say in the Middle East, it's common, too. Then in some countries, they like it more natural. What countries do you think like toilet bowl white, kitchen sink, and what other ones like them darker?

 

Naz:

First of all, I would like to say my country [views 10:10] about all the stuff. I prefer to have natural teeth, to have a nice, fresh light, but natural-looking teeth, because, in that case, for me as a clinician, I consider the case successful. On the other hand, I also understand people who are paying sometimes not little money for the treatment and they want to have the teeth that are really, really white. They can have a choice because they are actually paying for the treatment. We cannot say that this is improper treatment, because we have 2 goals for the treatment.

 

 

The first one is the health of the human. We can have a good healthy re-treatment or treatment even with the white teeth. On the other hand, we have the aesthetics. Of course, the aesthetics is different for different people. Some people like it more natural, some people think it's too yellow things, other people like it too bright.

 

 

Of course, USA is quite popular market for the bright teeth because I think, on some hand, nowadays the smile represent also the status of the person, like buying a nice Porsche. [The life of 11:12] the person shows that it can allow to buy a nice car. The same stories about the teeth because we know that, in some countries, it's not too cheap to make a beautiful smile. That's why people want to show that they afford themselves to have a nice and beautiful smile.

 

 

I wouldn't be too strict about this or other decision. I think people can decide what they like more. Me, personally, I prefer to have nice, natural, bright teeth. If people choose the white ones, sometimes I do those cases also.

 

Howard:

Besides the United States, what other countries do you think like really white?

 

Naz:

Actually, Dubai, they like a lot the bright teeth also.

 

Howard:

Dubai.

 

Naz:

Now I travel a lot to Saudi Arabia, beautiful country. Also, some of the patient, they prefer these kind, because I'm also communicating a lot with the other dentists. They're telling me what the patients usually request, how they communicate with them.

 

 

I think it's getting more and more popular everywhere. If you take Europe, of course, during the last 10 to 15 years, Europe was more like natural smile design, but even in Europe now, it's becoming more and more white teeth. It's actually [crosstalk 12:17].

 

Howard:

Is that because they're watching too many movies from Hollywood?

 

Naz:

Probably everybody wants to become Angelina Jolie or something like this.

 

Howard:

2016, what are you passionate about now? What's got you excited now at 2016? What gets you excited now?

 

Naz:

First of all, I'm very excited because I met the father of Dentaltown. That's a good one, right? Of course. I'm traveling a lot. This is why I like my work because it allows me to see the world, different countries of the world, because probably the countries that I will never go by myself - this is the point - because I meet so many nice and cool people and new friends. I learned a lot. I'm not just teaching dentistry, but I'm also learning from other people, how they live, how they see the world. This is a really great world experience for myself in my life, let's say it this way.

 

 

Also, this year, I'm planning to reduce the traveling because I want to do more cases in my clinic, because I have some new ideas. I'm trying to use now some new material on the market. I'm not going to tell you right now because it's going to be a surprise for the next year. Now we're also implementing lots of video materials. Now all the cases, we have a video team that's videotaping everything.

 

Howard:

Wow!

 

Naz:

Also, we are switching totally to the 4k. We're not doing Full HD anymore. All the videos that we are producing now is a 4K, so really nice, high definition material, let's say it this way. I think it will be very interesting to see for our colleagues from Dentaltown and from around the world.

 

Howard:

Wow! In the United States, there are 7500 labs. You're talking to a lot of dentists. If they want to do a high end cosmetic case, how would they find a lab to do more high end cases?

 

Naz:

I think it's not even about finding the lab, it's about finding the person, because what I can tell you, you can have a beautiful clinic or you can have a beautiful lab with an investment of millions and millions of dollars, but if people who work there are not really motivated, it will not bring you success.

 

 

On the other hand, we can cooperate with the person that's working alone or something like this, but who is really motivated to produce a high quality product. Believe me, you'll have a beautiful result of that person. I advise you not to look for the company, but look for the people because people actually create a company.

 

Howard:

Well said. What else has got you excited?

 

Naz:

Beside Dentaltown.

 

Howard:

Let's talk about some of the most different case. On the Dentaltown, they've posted 4 million times. When I go to cosmetic dentistry and I see the things that are stressing them out the most, I think the most stressful thing is a woman, attractive, high lip line, she breaks off one tooth.

 

Naz:

[crosstalk 00:15:06] cases or what?

 

Howard:

Yeah. What do you do when you have to crown one tooth?

 

Naz:

That's when I have a great benefit because I'm cooperating with a really good dental technician. For us, to perform one tooth is not a really big problem. My father is really high level, so he can copy easily, naturally the opposite tooth. We have plenty of those cases.

 

 

We're not doing ... Sometimes patients come and they say, "I broke the central incisor. I have been to some other clinics and they were saying that we need to fix to teeth because one will be visible." We're not trying to follow this philosophy. Usually, my father manages to fix one tooth that looks invisible, let's say it this way. Of course, from this point of view, you need a very nice dental technician and no CAD/CAM machine will help you.

 

Howard:

Yeah, a CAD/CAM where you're just going to mill out a monolithic block on a single front tooth. Why do so many people believe that that's just going to happen?

 

Naz:

It's like saying you pay money for a new tooth, so it's supposed to be more white than the other. Come on.

 

Howard:

Yeah. That is not-

 

Naz:

Nowadays dentistry is a lot about marketing. I agree that the marketing is good, promoting your stuff to the patients, but you have to have a nice balance between the quality dentistry and marketing of your dentistry. This is the point. Not to push too hard to market a low quality stuff, and also not to do a high quality stuff, but not marketing it, because if take a success in dentistry, probably I can split in 3 big parts.

 

 

The first part will be a science, how good you are as a clinician. What's interesting, nowadays there are many good clinicians who don't have many patients. Why? Because there is another big part that is important. It's actually the human behavior.

 

 

On the other hand, there are people who are very good talkers, way less good clinicians, but they have way more patients. This is the point. I think either of the sides is incorrect. You should be a good clinician, but also you should be able to promote what you're doing. I think this is the best way. When you're doing both things good then you're getting financially successful.

 

 

Then there is the third thing: you must know how to invest those finances to grow with your practice. If you don't know how to do this, you're looking for someone. I'm always giving a very nice example: my family.

 

 

My father's a dental technician. He is a person of artists, but if you ask him how much is his veneer, he probably doesn't know, but my mom knows. This is the point. He met the right person. This is the point. Either you learn how to invest or you find someone who helps you with the organization of the practice and all the other stuff.

 

Howard:

Do you also do root canals, extractions, dentures, partials, place in plants? What is your [crosstalk 17:52]?

 

Naz:

When I was starting, when I was not traveling, doing courses and stuff, I was doing differently. I was doing different stuff. I was doing a mixed dentistry. It was direct, indirect, and the treatment also those days, but nowadays we have a clinic with 3 dental chairs and 3 microscopes. Every professional in the clinic is working with a microscope. We have the whole workflow, starting from the hygiene, finishing with the surgery that is being done with the magnification, because, one more time, it increase the quality of the treatment.

 

 

This is why when I started traveling I understood that if I wanted to do something good, I need to reduce the field of my work. I chose to do indirect restorations, of course, because my father is a dental technician. I started to improve in this field, reading lots of books.

 

 

That's very important because here is so much material online that people are not using. That is just crazy, to be honest. You can learn many things like going to Dentaltown, for example. Even if you read all the cases, you'll already have a big pack of information in your head that you can use for your daily work. This is the point.

 

 

I think the biggest enemy for every single dentists is actually the laziness. They are too lazy. This is the point. They don't have to look for the other excuses, like the geography, the site of the clinic, the difference in the lab technician. It's all inside yourself. Once you turn on your brain, you can be successful wherever you are, whatever you do.

 

Howard:

Some dentists get nervous about bonding on an all-porcelain crown because they think the bonding agent irritates the pulp. A lot of dentists believe that if you bond on a crown instead of cement the crown, then you might, 10 years later, have a higher rate of teeth that needed endodontic therapy. What would you say to that?

 

Naz:

First of all, I would like to recommend not to listen to the rumors, but to refer to the literature because there is evidence-based information online that everybody can look, everybody can Google. This is the era of Google. Nowadays patients come and they know a lot about dentistry, they know about the occlusal concepts, they know about different kinds of materials. Of course, dentists are supposed to do the same stuff.

 

 

Don't believe to rumors and don't just listen to what the other people are saying. Go online, look for the articles, read the articles, and then you will understand what is the truth, because, otherwise, the dentist can be really easily manipulated by other people, because somebody can say E-max is the better restoration because you're going to have pulpitis or something like this, or some other problems. See, we have some international friends who also would have a podcast with Dentaltown. Wait for your turn, guys.

 

 

What I'm trying to say, those are old rumors. I'm using these with dentistry every single day, and, believe me, it works perfectly because the biomechanical features of the tooth can be easily restored with a ceramic restorations using the proper adhesive protocol.

 

Howard:

I want to ask you another question. Humans tend to be extremists, all or none. You have a beautiful woman. She lost her front tooth. It was extracted. Some people say, "I don't believe in bridges. I would only do an implant." Some people will say, "I'm more concerned about cosmetics. I could do a more predictable cosmetic procedure with a 3-unit bridge and a fourth single crown." What do you do when ... I'm sure if a short, fat, bald guy like me came in, you'd just make me a removable flipper, but if a really beautiful woman-

 

Naz:

Denture.

 

Howard:

A denture. If a really beautiful woman came in and she had a high lip line and she really only wanted beauty and aesthetics, do you only do implants? Do you sometimes do 3-unit bridges? Is there room for both, or is it all or none for you?

 

Naz:

For this particular case that you're saying right now, I would go, for sure, for the implant. If you're speaking about me specifically, if we speak, generally, about dentists, what I would say, do whatever you do good. This is the point. Don't start doing things that you're not able to do. If you're a good with the bridges, of course we cannot say that it's like black magic or something like this, when you're doing the bridge or something. We can do it.

 

 

In the past, when I was not doing implants, I was doing many bridges in my office. They still are working. Of course, if there is a chance to have a single implant and you have quite enough of knowledge and you have other specialists who can help you to accomplish the case this way, I would do it like this because this is the way how I would like to be treated myself. This is the point.

 

Howard:

Would you agree that it's a lot harder to do a single implant on a single incisor on a beautiful girl with a high lip line than a bridge? Would you say that's a higher skill set, or just a different [crosstalk 22:35]?

 

Naz:

The question is what are the aesthetic requests of the patient? If the girl is so beautiful, she will not really agreed to have a bridge because the beautiful girl wants to have all the teeth separately, she wants to use the floss between each single tooth and stuff like this. Once again, I think it's more about if you have a professional team who can accomplish this. This is the point. This is what I think.

 

Howard:

Are you doing any of the ortho yourself, or are you working with an orthodontist?

 

Naz:

Usually, I recommend my patients to visit ... There is a very good orthodontist who's working in Portugal, Nuno Sousa, if you know him?

 

Howard:

Yes, I do.

 

Naz:

He's right there, yes.

 

Nuno:

Thank you so much.

 

Howard:

A very handsome devil.

 

Nuno:

I'm here with one of the most famous dentists in the world, our friend Dr. Nazariy. Nice to meet you.

 

Naz:

Nice to meet you.

 

Nuno:

I'm proud to share the podium with you. It's a pleasure. Come on. Come in [crosstalk 23:33].

 

Howard:

Oh, my gosh.

 

Mark:

I have to say that these are the most famous dentists in the world.

 

Howard:

Eric, come on. Ryan, can you pan us all in? You guys come here and sit down.

 

Mark:

They are the most famous and the most skillful.

 

Howard:

You know what? Sit down because ...

 

Nuno:

Yeah, let me sit close to Naz.

 

Howard:

We're all on the same subject. We're all on cosmetic dentistry. You are a cosmetic dentist. You are a cosmetic dentist. You are an orthodontist.

 

Nuno:

It looks like we have Dr. Pelekanos here on the ... Dr. Pelekanos, we are waiting for you. Yeah, here in the back.

 

Naz:

We have a podcast inside of the podcast.

 

Nuno:

[crosstalk 00:24:17]. We are here waiting for you.

 

Male:

Exactly.

 

Naz:

It's a double podcast here.

 

Howard:

[inaudible 24:20]?

 

Naz:

Double podcast.

 

Nuno:

[crosstalk 24:23]. Come.

 

Naz:

Wait, wait. Excuse me.

 

Nuno:

Great. Come. [crosstalk 24:31].

 

Naz:

What is that?

 

Nuno:

Come sit here close to us.

 

Stavros:

Hello, I'm Stavros Pelekanos.

 

Nuno:

I was saying that I was very proud to be sharing the podium with these amazing men, these world famous Dr. Pelekanos, Dr. Nazariy Mykhaylyuk. It's a great pleasure for me to be here. I will give the word to Dr. Nazariy.

 

Howard:

You moderate this. This is your podcast. Moderate, because you're talking to an orthodontist, you're talking to a cosmetic dentist legend in South Africa. Tell me who you are.

 

Stavros:

Actually, I'm Stavros Pelekanos. I come from Athens, Greece. I am a prosthodontist. I'm doing also some surgery. That's me.

 

Howard:

You lead the discussion. What's hot and what's not in cosmetic dentistry?

 

Naz:

What's taught?

 

Howard:

What's hot and what's not in cosmetic dentistry?

 

Naz:

What's hot. I can say, for sure, that the guys who are sitting here are very hot in cosmetic dentistry. Excuse me. Please understand me in a proper way.

 

Mark:

I'll tell you. I'll [crosstalk 25:41]. I'm going to give him some credit because I think, these days, really the hot thing in cosmetic dentistry is orthodontics.

 

Nuno:

Oh, thank you so much.

 

Mark:

It's becoming the most important tool that we have to make, the biggest difference in, really, achieving the best results.

 

Nuno:

I would not say that we are the most important ones because even if I place the teeth in the right position, you guys need to come and to make things look nice, because many times, the teeth, they don't look nice from the beginning. You are the ones that make the patient feel really happy in a short time. Right, Naz?

 

Naz:

Confirmative.

 

Mark:

You know what? We have a discussion about the cost of patients for biology and for how much it costs to fix the teeth. The cost to the biology is the most important thing that we have to tackle. The orthodontists make that the easiest for us to fix.

 

Howard:

Us being the 2 old guys, I have to tell you ... How old are you?

 

Stavros:

49.

 

Howard:

You're still not in your 50s. Go home. You're still a baby. You're not even 50. I have to tell you this. When we were little, it's true, there was an orthodontic involvement. When someone had crowded teeth, they'd file them half down and do all these veneers. They'd remove so much tooth structure. 10 years later, when they did those upper teeth veneers, 10 years later, what percent of those teeth needed a root canal?

 

Mark:

20%?

 

Howard:

Yeah, 20%. When your only tool is a hammer, everything looks like a nail. They would just drill down all these teeth. You'd just look at these and you're like, "Wow!" It's a pretty girl. She just had some crowding. Now you filed down 10 teeth for a crown. It's like she has 10 little rice pegs on her teeth. Then they cement these PFMs. I'd really cringe. It's like you just orally abused her. It was gross. Now I would say that, 30 years later, your generation is doing it so much more minimally invasive. Do you agree?

 

Naz:

Yes. We are analyzing different things. We are starting from your generation, but we are also studying your [pluses 28:01] and maybe we're also studying your mistakes. This is also a big thank you for you because we don't have to do the same mistakes again when we are doing this.

 

 

Of course, knowing how to remove teeth and also knowing how to work with the magnification, we're going to have the very thin veneers, like 0.1, 0.3 millimeters, and have already aesthetic and functional upgrade, and understanding that even with the approach that you had, you were successful. If we change the approach to the one that we are using nowadays, probably it's going to be even more successful than it was in the past. I think we're going to the proper direction. This is the point.

 

Howard:

My job is to guess what they're thinking. In the 150,000 Americans, you're talking to ... It's about 8,000. Probably 83% are Americans. When you say 0.1 and 0.3, they believe that if you don't have a millimeter and a half reduction, it's all going to break. When you say 0.1 or 0.3, half the audience just said, "Are you crazy? Those will break." How would you address that?

 

Naz:

I've been to the doctor, I'm fine. Actually, when people think that the veneers 0.1, 0.2 millimeters are going to break, that's mostly classical approach in prosthodontics. Those are people who are mostly using in the past not bonding, but cementation.

 

 

I also understand them because if I was doing the same stuff for so many years, I would probably think the same way. Nowadays we all are using adhesion. If we are clear with the protocol using isolation and all the other proper steps, we see that the final outcomes are really good. Of course you can break it when you're holding it in your hands, but if you bond it properly in the patient's mouth then it's working perfectly.

 

 

Don't be afraid. Believe me, we've done many cases - not just me, but many professionals in the world - and the results are great. Just follow the protocol and you'll be successful.

 

Howard:

I want to ask you a question and I want you all to go around and answer it. If I analyze the 4 million posts on Dentaltown, a lot of things everyone agrees with. Some things are extremely controversial.

 

 

I would say the most extremely controversial thing in Dentaltown is actually a occlusion. It's almost like religion. It's either you're a Buddhist, or a Muslim, or a Hindu, or a Christian. There is a neurological occlusion, there's neuromuscular occlusion. There's all these different occlusions.

 

 

Some people say, "Dude, occlusion doesn't even matter because when they eat, their teeth never even touch." What would you tell these young dentists who are coming out of school ... Because most of what you're talking to is under 30. Probably 20% of those people in the camera are in dental school and the other 80% are probably within 5 years out. There's all these marketing for neuromuscular CR, all these different occlusions. How would you define occlusion? In what camp should they go learn if there's all these different camps?

 

Naz:

[inaudible 31:06].

 

Nuno:

As an orthodontist and the way I was trained, I can say that I know nothing about occlusion and no one knows nothing about occlusion. You need to have knowledge in the medical field more than in the dental field. If I can give any advice to the people that are just graduating, as you said, is a field that needs to be explored. We know few things about it, but we are not sure about them. Do you agree with me, Naz? No?

 

Naz:

Yes.

 

Nuno:

A lot of things, I think, with more knowledge, we will have better answers for these. Many people, they believe in some things. They are really very dogmatic. I don't think we have at the moment the right answer. These is what I can say about occlusion. Do you have something to add? [crosstalk 32:03].

 

Naz:

I can just say that ... You were asking about which club they should join. If there are some nice girls, they can join my club. Continuing with the occlusion, of course, different schools, like neuromuscular approach, like Slavic school or CR position for [inaudible 32:18].

 

 

Personally, me, I'm speaking just about myself as a clinician, not a scientist, I'm using the CR position. I'm doing quite a lot of full mouth reconstructions. For me, it works good because it's repeatable. It's not some kind of information that you are talking about from the podium, trying to play a smart guy or something, but this is the stuff that you can go home and you can repeat with your patients.

 

Nuno:

You should give to the audience a definition of centric relation because, as you know, we have more than 11 definitions, different definitions, about this. The problem starts there. Many people comes with different definitions, with different approaches, with different blah, blah, blah, and we don't have a good answer.

 

Naz:

Yes, just not to get them a lot confused, we just recommend them to read the book from Peter Dawson. This is the one that I believe in.

 

Stavros:

[inaudible 33:09].

 

Male:

What's the name of the book?

 

Nuno:

Let the prosthodontist talk, Dr. Pelekanos, too, to bring something [inaudible 33:14].

 

Stavros:

Actually, I think we have 2 schools usually when we're going to meetings. We have the American school, going almost always every case in CR, and we have the European school, which, actually, they don't care too much. They erase the vertical dimension, also in the maximal intercuspation.

 

 

Actually, for me, I agree with Nazariy that raising the vertical dimension is a way to be more conservative, because then you don't have to prep the teeth too much. For me, this is a very important tool, especially for people that they are bruxists or for bulimic people that have abrasions in their teeth. I always go for vertical dimension, raise the vertical dimension in CR. Tomorrow, I will also show in my presentation some ways to do it.

 

 

It's very repeatable. You need some experience to do it by hand, manual manipulation, but using the [anteriority 34:21] programmer is very, very important. I will show you tomorrow how to do it in my presentation.

 

Nuno:

It's the short way. The fact that it is repeatable, does it mean that it is the correct way? If it's difficult to-

 

Stavros:

What you are looking at is not the repeatability, it's the comfort zone of the patient.

 

Nuno:

Yes. This comfort zone, do you trust the patient opinion, or is it something that is measurable? Because if you tell me I placed some device that actually is measuring the activity of the muscles and I see if I placed the mandible in this position, it's in balance; it's repeatable, but is in balance. This is what we called normal, I agree, but what we do in 2016, we don't really use anything with precision to come to this conclusion. We don't say, "Do you have pain?" "No." "Do you have [gleeks 35:21]?" "No."

 

 

How many diseases do you know that there is no pain and this patient is almost dying? Like cancer. "Do you have pain?" "No." Is it normal? No, it's sick. We believe that pain, gleeks ... I think we are very much below the right answers.

 

Stavros:

No, no. you cannot measure it-

 

Nuno:

We can measure it.

 

Stavros:

But you have a very good tool in your armamentarium. That's provisionalization. With your provisionals, you can check it.

 

Howard:

Can I just say-

 

Nuno:

Just one thing: how can I do this with orthodontics?

 

Stavros:

I told you, yes, there is a big problem [crosstalk 35:55].

 

Nuno:

There is no provision?

 

Mark:

Also, as we move more into the minimally invasive type dentistry, the provisionalization becomes more of a problem. It becomes really difficult. We do bonded transitional restorations in our practice to work out the occlusion and see how it's going to work.

 

 

I have to say, in my opinion, that I'm on both camps, that I think that actually the CR or maximum intercuspation, it's really both of them are working for patients. I can't honestly tell the difference in these groups over the years that I've treated-

 

Male:

I think [crosstalk 36:34].

 

Mark:

But one thing that I would say, that when do all our full mouth rehabilitation, we give very, very good anterior guidance that's very gentle for the patient, that they can manage smooth transitions. Then, for sure, I tell them that, "If you can destroy your teeth, you can destroy my dentistry. You have to wear night guard."

 

Naz:

Actually, I agree with [crosstalk 36:59].

 

Stavros:

One more comment. Nuno, also from orthodontist, that the most difficult patient we face are the class II patients. These patients-

 

Nuno:

[crosstalk 37:09].

 

Stavros:

They don't have any guidance. These are the most difficult-

 

Male:

[crosstalk 37:14].

 

Stavros:

Yes, [inaudible 37:15].

 

Howard:

Why are they the most difficult?

 

Mark:

The guidance [to the teeth 37:20] is locked. They cannot move freely.

 

Nuno:

You need [crosstalk 37:24].

 

Mark:

They're locked in one position.

 

Howard:

Talk into the mic.

 

Nuno:

Tell me [crosstalk 37:30].

 

Male:

They're locked into a position. I have a case tomorrow. I'll show that we have a class II. It's a class II. We do orthodontics for all these patients. We don't treat these rare cases until we moved the teeth into a more manageable position from an occlusal point of view.

 

Stavros:

I totally agree. I try to reduce the vertical overbite and I try to reduce the overjet. Once you go for full mouth rehabilitation ... Because these patients in class II, they can work once they have their own teeth, but once you go for prosthetics then it becomes critical.

 

Nuno:

Because usually the muscles are very strong with these patients. They break, what do you do?

 

Naz:

That's actually too bad that you were not on my lecture in the morning, because actually my lecture was about the CR. 2 hours, I was showing 4 full mouth reconstructions.

 

Stavros:

I would do the same.

 

Naz:

Yeah? That's nice.

 

Nuno:

But we didn't have place in the room because the room was full.

 

Naz:

Yeah, that's for sure. The point is I'm always recommending to use the CR in 2 cases: when I have a full mouth reconstruction or when I'm working with a full arch. You can give your patient, not only nice tooth structure, but you can give him health, you can give him relaxed muscles, plus a nice tooth structure in the end. This is the point.

 

 

Also, I was showing the case today, when the patient came with a full mouth reconstruction already done 3 years ago. Yes, she has also some kind of MIP that was created for her. If I will just follow this MIP approach, then what am I supposed to do? Just remove these restorations, put new ones, and that's it.

 

Howard:

A lot of us still don't know what MIP means.

 

Naz:

Maximum intercuspidation.

 

Nuno:

Intercuspidation or intercuspation or whatever, this doesn't matter. What is important is-

 

Naz:

Wait a second. Let me finish.

 

Nuno:

Okay.

 

Naz:

One second. The point is if the patient like this comes to my office and the patient is ready to finance the treatment, and if I'm just going to remove all the old restorations and put into place the new ones with the same bite, this is not a treatment. It's called a aesthetic upgrade, because the patient still will have the lateral pterygoid muscle that is tense, all the time working, temporalis, the masseter, and all these stuff going on. What I want to do, I want to relax the muscles to create [inaudible 39:58], as Stavros was talking about. Then fix it with a beautiful restorations.

 

 

This patient who came already with a full mouth reconstruction, when I deprogrammed her, I've got a gap about 3-1/2, 4 millimeters on the front. If me, as a doctor, if I'm going to fix the position how she came, this is not a treatment; this is earning money. This is the point. This is how I think.

 

Stavros:

I would like to hear Nuno because, at least in Greece, we have a lot of problems with the orthodontist. When they are finishing cases, really the occlusion does not look good. I want to hear your opinion about it.

 

Howard:

Explain what you mean by the occlusion [inaudible 40:38]. Is it because they blow out their Curve of Spee or their Curve of Wilson, or they're not closing the teeth? Explain what you mean by you don't like the occlusion.

 

Stavros:

Actually, there is no maximum intercuspation. We have some contacts in molars, maybe second pre-molar, and then there is a gap between the teeth when the patient are biting. Do you really consider about detail the occlusion after the finalization of the treatment?

 

Nuno:

Again, this comes a very delicate subject, but that is-

 

Stavros:

Sorry.

 

Nuno:

No, it's delicate because, again, me, as orthodontist, and the orthodontists, they are dentists. As you showed me in that picture, the dentists are not orthodontists. What do I mean with this is that I understand when you with pros work go in precision as Nazariy was mentioning, doing preparations of 0.1, but we, as orthodontist, work with biology. A lot of skills are required.

 

 

Even if now we have SureSmile and all the systems to finish the things perfect, we will never be able to finish an ortho case as you do a pros case. In 2016, even if it's a top Japanese orthodontist, that kind of orthodontist, it's really difficult. You as, a prosthodontist, need to understand that this is our limitation.

 

Naz:

Question.

 

Nuno:

Okay, sure.

 

Naz:

For example, if we ... Just really when I asked you what you think about it, for example, if I have a patient who came to my office and needs ortho, and if I start the treatment from deprogramming, I do the registrations, I send it to the lab. In the lab, with the CR position, we actually create centric occlusion for the patient. We'll make a setup of the teeth. Can you, as an orthodontist, create this for me? If I make a setup for you and I say, "Nuno, I want the teeth to be like this," can you do it in the patient's mouth? Why am asking? Because as-

 

Nuno:

I understand what you mean. I think the right answer for this is that, in some patients, I will be able to do it, because I will be lucky. In some patients, no. It will be dependent on my skills, it will be dependent on patient biology, because maybe, let's say in this very simple example, we are closing spaces. Same patient, same mechanics, same amount of force. One side closes faster than the other.

 

 

We have to understand we have this limitation. In some cases, we will finish perfect. We would take these cases to the meeting and we show, "Wow! This is [inaudible 43:17]."  It's not like this, not like you. You can do the same pros work and you'll get the point of perfection of skills. You will get the skills and the training and the learning curve. You'll get to a point of almost no failure. With us, it's not like this. This is my feeling.

 

Stavros:

Can I interfere, Nuno?

 

Nuno:

Yes, sure.

 

Stavros:

I was amazed now by Nazariy because how many dentists really do the setup?

 

Nuno:

Sure. This setup is the same concept.

 

Howard:

[inaudible 43:48].

 

Stavros:

The setup is done usually by the technicians, and this is not the correct thing to do. The dentist should do ... Which means you have to cut the tooth in the right position and then you have to transfer the tooth in the correct position.

 

Nuno:

The way I work and the way I was showing today, if we do digital setup, that is quite easier comparing to the old way. We can easily communicate between the team and find a reasonable or several reasonable treatment goals. We can move the teeth digitally, we can discuss with the team ...

 

 

The prosthodontist is asking me, as you said, "Can you move this tooth to this position?" Me, as orthodontist, I have to be careful with the answer. I have to say, "Is it possible?" "Yes." "Are you able to do it?" "I will do everything in my power to do it." Sometimes we will not achieve this, for many reasons, but the way to communicate is, as Stavros said, doing a setup and using these to communicate between the team. Yes?

 

Howard:

I don't think a lot of Americans know what you mean by a setup.

 

Nuno:

A setup is having the initial malocclusion. Digitally, we can extract teeth, we can move teeth, rotate them, in order to have an idea of what the final result will look like. This is what prosthodontists, they do. This is part of the DSD show ... The emotional dentistry means.

 

Stavros:

It should be done by the restorative dentist. This is the guy responsible for this.

 

Nuno:

As [Christian 45:32] said, it should be done by the smile designer-

 

Stavros:

Yes. [crosstalk 45:37].

 

Nuno:

Because you, as a prosthodontist, you do some setup when you move one molar 10 millimeters. As an orthodontist, I'll tell you, no, I cannot do that. It should be done by the team. It's difficult, but the team should be together to do this and to discuss about this and to write down treatment goals and treatment plan. This is what I call ... The excellence in dentistry is having a patient with 1, 2, 3, 4 doctors with different specialties, and discuss and finding a conclusion in [spot 46:03].

 

 

Is it difficult? Yes. Is it expensive? Yes. Are we doing this? Probably not everyone, and this is what makes people different, one from each other. In my opinion, this is the excellence in dentistry. Naz?

 

Naz:

Very good. Very good. You were talking so nice that I wanted to write it down, but I didn't have a pen.

 

Nuno:

At least you can recall with your [inaudible 46:28].

 

Naz:

I'm going to have it in the iWatch.

 

Nuno:

The iWatch.

 

Naz:

It's recording everything, yes. What I want to say is that what I also noticed, that's why I was asking you those questions about the CR position, that most of the patients who had ortho treatment, if we deprogram them, which at least we deprogram as much as we can, this is what I mean, most of them will have a supracontacts [inaudible 46:49]. That's why I was asking you, like I would really like to cooperate with the orthodontist who can-

 

Nuno:

Then why do you think that deprogramming the patient is bringing the patient to the normality? [crosstalk 47:01]?

 

Naz:

Because normality ... Do you know what is normality?

 

Nuno:

[You tell me like this 47:06]. These patients, when it's not deprogrammed, it's not in balance. The situation as it is usually is wrong. Now I'm deprogramming the patient and now he's in balance. The muscles are relaxed. This is the rest position. Where do you measure this? You ask the patient, "Do you feel better now?" "Yes, now I feel good." Where is this? If you measure this, show me and I agree. If you don't measure this, I still believe that we are not machines that is arranged. The answer is probably between [crosstalk 47:39].

 

Naz:

Look, I can give you a [comparance 47:40], ergonomics in dentistry. If I'm a dentist who is not using magnification-

 

Nuno:

[crosstalk 47:45] robot. You do like this or you do it like this.

 

Naz:

I'll give you a parallel. When you're working like and your muscle is always tense, of course, in the end of the day, you're not feeling comfortable. The same story is about your muscles in your face. If your muscles all the time tense because they are supposed to hold the mandibular, in some specific position, because of the supracontact [inaudible 48:08], it means that your muscles are always tense. Do you know when those people are most comfortable? When they wake up in the morning. Why? Because in the morning, they are not biting, they don't have a bite. They have a relaxation of the muscles. I know because I'm one of them, one of those patients.

 

Nuno:

[crosstalk 00:48:24] I have patients that are the opposite. When they wake up, they have pain.

 

Naz:

Yeah, those are people who are bruxists.

 

Nuno:

[crosstalk 48:30].

 

Naz:

We have 2 groups. We have to clearly understand.

 

Nuno:

[crosstalk 48:33].

 

Naz:

Wait a second. There is information. There are clenchers and there are bruxists. The clenchers are people who are parafunctional during the day, like me, for example. Bruxists are parafunctional during the night. For me, I'm really-

 

Nuno:

I understand. This is what comes in the books, but if you think properly, you can say that there are people that are bruxists. What is this exactly? Why are they doing this parafunction?

 

Stavros:

Nuno, do you know-

 

Nuno:

There is another reason. When we don't know what it is, it's stress.

 

Stavros:

Nuno, I think Nazariy is making a point. You don't have to make every patient in this CR ... Only if you are doing a case, where you are doing the full maxilla or the full mandible or upper and lower together, then it's more safe to go in the CR position. I think this is the point.

 

Naz:

We're not speaking about each tooth doing the CR position or something. That's the point.

 

Stavros:

Yes, exactly. Don't misunderstand Nazariy. I'm thinking about full mouth cases and I'm talking about restoring upper or lower, or both. You agree about this?

 

Nuno:

I agree. If you tell me as a prosthodontist that this is what you do, and it works well, I cannot say that it is not like this because the only thing I'm saying is that I don't have a right answer for these, and we are hearing this discussion to try to brainstorm this issue in order to get to some conclusion. I tell you my issues.

 

 

Do I understand about TMJ in order to discuss this properly? Probably not, not me, and not 99% of the orthodontists. Is this the reason that they don't finish the cases, as you are complaining? No.

 

 

The issue is some of them, they are not skilled enough. Some of them, they don't get enough. Some of them, they are just not lucky enough because the patient is not the patient that we might achieve this. It's complicated. It's not like mechanics, it's not like  mathematics. It's really complicated.

 

Mark:

Yeah. Listen, I agree with you. I'll throw a spanner in the whole works because what about, for instance, and that's not my preference anymore, I have to say, but there's a lot of time still where these rare cases are being treated with the Dahl appliance, where we're just opening the bite in the interior and leaving the occlusion. We're talking about now the orthodontist having to finish everything in beautiful in occlusion. As prosthodontist, we're just taking something and actually doing the opposite as a form of treatment. How does this fit in?

 

Nuno:

Explain to me exactly what you are saying. Let's say that I finish a case, that the [crosstalk 51:16].

 

Mark:

I'm saying that if you have a space in the front, they're making an open bite in the posterior. They're creating the open bite.

 

Howard:

Is it because you're putting in [inaudible 51:26]?

 

Mark:

Because they don't have any space to restore the anterior teeth. It's really an interesting concept, that, for one part of it, we say we have to finish with this occlusion. Now there's another prosthodontic process, which means that we must now open the occlusion.

 

Naz:

What I'd like to say-

 

Nuno:

[inaudible 51:46].

 

Howard:

Come here.

 

Stavros:

[inaudible 51:52].

 

Howard:

Come in.

 

Naz:

The problem is that quite often surgeons decide by themselves what they have to do. Orthodontists, they have to decide by themselves what to do. Some other guy, dental technicians are also supposed to decide by themselves how to accept.

 

 

I think the guy who is the most responsible is the doctor who accepts the patient the first time, the restorative guy, because he's supposed to give you the goal, what to do. You're not supposed to figure out what to do. I'm supposed to call you and say, "Look, Nuno. I would like the teeth in this position," because I'm the guy who is going to finalize the case. The same story, I was supposed to call the dental technician or the surgeon and tell them what I want from you as a specialist. This is the point. Then when you have a goal, then you-

 

Nuno:

I don't agree. Let me give you-

 

Stavros:

This is a team approach, Nuno. This is a team approach.

 

Nuno:

No. This is a prosthodontist approach.

 

Stavros:

[inaudible 52:45].

 

Nuno:

The team approach is that, in my opinion, some cases should be guided by the pros, some cases should be guided by the ortho-

 

Stavros:

Thank you.

 

Nuno:

There is no right answer. The idea is each case should be looked together.

 

Mark:

Can I just say that the case should be driven by the face, not by you or by you ...

 

Nuno:

Who knows about the face? It's the orthodontist.

 

Mark:

I think we all know about the face. We know that each case must be driven by the face and by function.

 

Nuno:

This is theoretical, but when I tell you and you tell me, "Okay. We have this proclination," and I want to push this back. Nazariy, as a prosthodontist, he's doing a setup. He's changing the position of the teeth. He tell me, "Nuno, put the teeth in this place." Does he know what will happen to the lip?

 

Mark:

Of course, that's ...

 

Naz:

[crosstalk 53:35].

 

Mark:

That's why it's a facially-driven-

 

Nuno:

This is my question. Who knows about this? Who knows what will happen to the patient-

 

Mark:

I'm not saying that-

 

Nuno:

In 30 years in terms of growth?

 

Mark:

It's a facially-driven plan.

 

Nuno:

Who knows about growth. Who knows about growth and development? [crosstalk 53:46].

 

Mark:

We all have to make those decisions.

 

Nuno:

It should be all the team together.

 

Mark:

Of course, but it's the face that drives the treatment.

 

Nuno:

The idea that the orthodontist is looking to the plaster models and just wants class I, this is finished.

 

Mark: