When we studied occlusion at Dental School, our textbooks forced the idea of having dots at the back and lines at the front. We are continually told about CR and how to manage patients into canine guidance, but does this all work in practice?

Today we dive into the best way to approach occlusion cases with our patients, keeping in mind that there is no such thing as a silver bullet to treatment. Join Jaz and Dr Michael Melkers in this podcast to learn how it may just be time to throw away the textbooks and begin writing your own conclusions on occlusion… try saying that ten times quickly.

https://youtu.be/3Sk1paKW8d0
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Dental Pearl 

Using PTFE in the dental sulcus offers a better seal compared to cord, functioning like a dam to keep the area free of gingival fluid, ideal for Class 5 restorations. However, PTFE may stick to instruments, which can be mitigated by moistening the instrument with water or saliva before positioning the PTFE, significantly lowering the likelihood of sticking. 

Check out Dr Melkers and Dr Lane Ochi LIVE IN LONDON on 27 and 28 July!

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

Highlights of the Episode 
00:00 Intro 
02:05 The Protrusive Dental Pearl 
02:52 Dr. Michael Melkers 
02:53 Mentoring Journeys: AES and Beyond
04:04 Foundational Influences: Splint + Occlusion Mastery 
04:30 Fear of Failure: A Dentist’s Drive
05:25 Early Beginnings: Lab Tech to Dental degree 
06:00 Avoiding Full Mouth Rehab: A Dental Mission.
07:20 Homage to a Mentor: The Positive Impact 
07:25 Group Function Vs Canine Guidance
08:00 Beyond textbooks: real-World Dental Challenges 
09:00 Encouragement to Question: A lesson in Bravery 
10:16 Chasing Perfection: A dental dilemma 
12:00 Masters of Occlusion: Group Function Insights 
14:31 Past as Prologue: Learning from destruction 
15:10 Pain Points: Focusing on the At-Risk Patients 
16:53 Smooth Transitions: The Ideal of Disclusion 
18:30 Occlusal Schemes: Debunking the Malocclusion Myth
20:20 CR Reconsidered: The Healthy Majority 
22:44 Diagnostic Vision: Seeing Beyond Occlusion 
25:15 Rebuilding with Purpose: Beyond Aesthetics 
34:35 Appropriate vs Ideal: A New treatment Paradigm 
47:00 Key to Dental Success 

Access the CPD quiz through our app on https://www.protrusive.app, either on your browser or by downloading our mobile app. For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you liked this episode please feel free to check out episode PDP160 – Fremitus and Occlusal Overload – Dental Occlusion Geekiness

Click below for full episode transcript:
Jaz's Introduction: In this episode, I'm going to share with you the four ways that I document my daily dentistry. And I'll give you six great reasons in reverse order. So like my top six, if you like. So six, five, four, the countdown all the way to the number one reason. So if you listen to the end of the episode, I'll tell you the number one reason to document your dentistry.

Jaz’s Introduction:
And when you grind your teeth left and right, the canines, for example, are taking a load at that point. And when this is happening the patient’s joints are in centric relation. So the condyles are as fully seated position is snug position, and there are no quote unquote interferences or slides. I don’t worry if you don’t know what those things mean just yet, but some of you may remember seeing this.

Maybe you don’t understand or internalize what this actually means, but you learn what the perfect occlusion was. But then you started to see patients and you realize very quickly that these naturally dentate patients, your normal patients with the normal teeth. Whether they were 30, 50, or 70, they had all sorts of restorations, or sometimes no restorations.

But they had anterior open bites, cross bites, and none of it looked like the bite in the textbook. No one had the perfect occlusion. And that made me really question what was going on. And when I did check my patient’s excursions, lateral excursions, most of my patients were in group function. In fact, guys, the next time you check this, don’t just get the patient to slide their jaw left and right, get them to bite firmly and grind left and right.

You’ll notice that very few patients are in true canine guidance. And even the literature supports that those in canine guidance are the minority, not the majority. But the textbook, the textbook said Canine Guidance! And we kind of have this perception that group function was bad or inferior and canine guidance was like the thing to aim for.

So what does that mean? Does that mean our patients who don’t have canine guidance, they are diseased or disadvantaged in some way and we should be restoring the canine guidance on these patients for every single patient? Well, this is a huge topic and it may sound simple, but my goodness, I had a challenging but a fun time with my mentor, Dr. Michael Melkers. I know he’s been a mentor for so many of you as well, but he’s the guy I think of who really helped me in my journey so that occlusion and occlusal appliances really started to make sense.

Dental Pearl
Hello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. This one is about working with PTFE. It can be quite difficult. For example, when you’re trying to use PTFE in the sulcus, kind of like cord, I find this gives you a really superior seal that kind of like dams the sulcus, so no gingivocricular fluid can come up. Your tooth is going to be bone dry.

I like to use this technique for class fives, for example. Now, when you’re actually handling the PTFE, it can be quite tricky because the PTFE sticks to your instrument. So what should you do? It’s actually really simple. You just get your instrument, whether it’s a flat plastic, a wards carver, or a fancy cord packer, and you either dip it in some water, like in a dappin spot, or you dip it in some pool of saliva.

Not yours, the patient’s. And then you start pushing the PTFE. The PTFE will have a way less chance of sticking to your instrument, and you’ll have a lot more success. Now let’s join the main episode, and I’ll catch you in the outro.

[Michael] Mentoring Journeys: AES and Beyond
Hello everyone, I’m Dr. Jaz Gulati from the UK, and we have a very special guest, Dr. Michael freaking Melkers from Hanover, New Hampshire. Oh, Michael has been a mentor of mine for so long, and he took me to the AES, where it’s in the joy. So, without further ado, let’s bring Michael on.

[Jaz]
That is- But for those who are listening on Apple and Spotify, I’m sure you got a kick out of that because that was actually Michael, not me, just in case anyone confused that. But what you didn’t see was Michael had this like a COVID mask as the make do beard and like these black tape there as a mustache. And you’re just missing the turban, man. Should’ve got like a black towel and just like, ah, that’s like a swimmer.

[Michael]
Yeah, I look like, I don’t know what I look like, I don’t like that look, that’s not a good.

[Jaz]
Like some sort of ninja. Anyway, Michael, it is a great pleasure to see you again, you kind of did the whole intro for me. You’ve been on the podcast before, but just for those people who may be new to the podcast or haven’t heard of you I’m going to say a little bit about you, if you don’t mind, before I’d like you to introduce yourself.

Foundational Influences: Splint + Occlusion Mastery
But Michael has been a huge inspiration to me in my career. So much of my occlusion and splint comes from Michael. He is such an approachable person, kind, and his expertise and influence in terms of communication and the style of communication has been absolutely fantastic. Michael, what drives you?

What are you about my friend? If someone’s listened to you for the first time, how do they introduce you? I just feel as though I know you too well. So I’m going to let you introduce yourself like a speaker roster kind of thing.

[Michael] Fear of Failure: A Dentist’s Drive
Well, first of all, I think my top credential is I’m a massive coward. I hate failure and that’s really what does drive me. I like to avoid failure as much as possible. And I like to share that with others because I think some of the things that beat us up the most in dentistry are our failures in ourselves is we think we’re supposed to be perfect. And anytime anything goes wrong that our mom wouldn’t absolutely think we’re the best thing in the world.

We’d beat ourselves up. We want to quit dentistry and go into diesel truck driver training school. So I’m a restorative dentist. I’m not a specialist. I’m a generalist. I practice in Hanover, New Hampshire, full time. Aside from that, I wear a few different hats. So I’m visiting faculty at the Pankey Institute.

Early Beginnings: Lab Tech to Dental degree
I’m also on their board of advisors. I have been faculty at the Spear Education where I taught with Frank Spear. I have been a laboratory technician for my father since I was about 14 years old, until I graduated from dental school. So I have studied under Kois, Spear, Dawson, Jeff Brucia, many of the UK people, Lane Ochi is my teaching partner.

I know you’ve had Lane on before and we’re all good friends. Some others might not know that, but all the way back to the beginning, I’m a wet finger dentist and I pay my bills with single crowns. And just all the same patients that you do. Yes. I do a lot of full mouth rehabs, but that’s not my focus.

Avoiding Full Mouth Rehab: A Dental Mission.
In fact, I’d like to keep people from needing full mouth rehabs. So in a nutshell, I guess, that’s who I am. I’m my father’s son and I’m hitting my, believe it or not, I’m hitting my 30th year in practice. And if you throw in my laboratory technician side, I am coming up on 50 years of practicing dentistry on one side of the bench or the other.

[Jaz]
What a remarkable introduction there. Things that you didn’t mention is you’re a cat lover and a hot dog lover, which I learned. I mean, I remember Mahmoud eating into that hot dog. What was it? Is it a chili of the caper? What was it that spilled in the dill? Was it that spilled in your eye?

[Michael]
Oh yeah. He bit on the sport pepper, which is basically like a little teeny pepper chili and it squirted across and it just hit me right now. Thank God I had my safety glasses on. So otherwise I would have gone blind.

[Jaz]
And when you came to Dental Tubules a few years ago, I remember I had the pleasure of introducing you on the stage there, and I introduced you as a crazy cat person. And literally, like, for those who don’t know this, Michael was Whatsapping me just before he went on.

He was like, I’m just going to find a relatively cat free area, but there we are, just behind him, guys, he’s pointing to a cat silhouette right behind him. Well, Michael, I love your intro, I love everything about you. Today I want to discuss on the podcast, kind of like a philosophical topic when it comes to occlusion.

Homage to a Mentor: The Positive Impact
Like you are, in my eyes, like you are a master and everything you do, huge inspiration, like I said.

Group Function Vs Canine Guidance
But one of the things that I’m sure, because I’ve done it, that young dentists are googling when they’re trying to make sense of occlusion is group function versus canine guidance. They’re just trying to get a grips with it, like, which is superior? It’s almost like a battle. And if you don’t mind, I’m just going to share my own confusions when I qualified from dental school.

[Michael]
Sure.

[Jaz] Beyond textbooks: real-World Dental Challenges  
That you look at this textbook and you see this, the mutually protected occlusion, the dots at the back, lines at the front, the cuspid guidance, and everything, the condyles being fully seated and everything touching together, i. e. the patients are fully and beautifully equilibrated intercentric relation. But when you go on the clinic, or when you go in the real world, my patients have anterior open bites, cross bites, all sorts of a word you don’t like, interferences, we’ll go into that actually. And it just didn’t match the textbook. I remember that, of course I remember that. It just didn’t match the textbook, and so I came out of dental school being very confused. In fact, Hap Gill, who was my principal.

[Michael]
Good friend, yeah.

[Jaz]
Hap’s obviously trained with Panky as well. And I remember shadowing him. Like, one year out dental school and he was finishing up an orthodontic case and he was checking the occlusion. And I noticed that it was very nice and smooth group function. And when the patient left, I said, Hap, what about the canine guidance? And he said to me, Jaz,, whoever filled your head with that nonsense, get rid of it. So let’s try and unpack the journey of learning inclusion.

I don’t even know how to like, begin to asking you the about these questions, except the first place I’m going to start is, did you also have this similar feeling in terms of what the textbook was saying and what the patients were displaying to you when you qualified?

[Michael] Encouragement to Question: A lesson in Bravery  
Yes and no. The reason I say I didn’t have the confusion, I don’t think I was bright enough to ask the questions. I was given this instruction book that was, Peter Dawson for me, when all those dots and lines. And so in the U. S., dental school is four years after university. So we have our undergraduate degree and then our dental degree. So when we get into that, we’re still doing two years of basic sciences before we even start treating to patients.

But we’re given a book the first year with all those dots and lines, and we have no idea what they mean, and we have no idea how to apply them, but yet for two years we basically study full mouth rehabilitation in a class one environment. So it’s a perfect dentition with perfect dots, perfect lines, and then you go into the real world and you realize those people don’t exist.

The analysts of anatomy did a study a few years ago and they looked at a hundred people and none of them were in centric relation being equal to MIP. And that’s a whole nother story before, maybe before we even get to group function versus canine, or maybe we can talk about it later. When you talk about this, that everybody needs this perfect occlusion, it’d be like if we’re ophthalmologists and go, Oh my God, mate, you have two eyeballs.

Chasing Perfection: A dental dilemma
You need glasses. We need to get you glasses because you have eyes and but that’s how we approached occlusion is we think everyone has to have this perfect occlusion and at some point you and I both and I appreciate all the kind words you say to me and I remember all the times that we’ve met and we’ve gone over all these things is you have been a master at erasing all the BS that goes along with the mythology. So I welcome the chance to chat. Get me back on track here, Jaz. I went down five radicals on you.

[Jaz]
No, no, because this is such a huge, huge topic. And it’s very difficult to boil down, but we will try our best. And I love the direction that we’ve already gone in. But essentially you said that those perfect occlusions, they don’t exist.

And it’s trying to then make sense in how it goes. And also in the TMD world, I got more and more into TMD, and when a dentist is speaking to me, and they’re wanting to describe a scenario of their own patient, what they start with is, Jaz, I have a patient with TMD. Their group function on one side and canine guidance on the other side.

And they expect me to just give them the answer in terms of what’s wrong. And so I think we’ve put like so much emphasis on this sort of characteristic of the occlusion. And so I think what we really need to do is just go back to basics in the sense that when we see that perfect occlusion in the textbooks and the fact that we don’t see in the real world at all virtually like no natural occlusion that I’ve seen in someone who’s 50, for example, will ever match what the textbook says.

So how about we just for the sake of the dental students, let’s just spend a minute to revise. What is the ideal occlusion as per Dawson and the textbook? Let’s just go from there and then say, okay, what do we see in the real world? And then try and fill in the dots in between.

[Michael] Masters of Occlusion: Group Function Insights
Well, filling the dots in between. It’s funny if you go back to Dawson and many of the heritage masters. They didn’t believe in canine guidance. They believed in group function, but we didn’t listen because the exam that we took, the correct answer was canine guidance. Canine guidance is a component of group function. And so, if we’re going to talk about this, we have to talk about terminology. And I’ll ask you, Jaz. When you were taught group function, what were you taught that it actually met?

[Jaz]
I was taught that group function was when someone goes to one side to their working side, so the right excursion that they’ll be touching on. It could be their canine, for example, but it would also be at least one other premolar.

And ideally, I think probably if I’m really trying to tap into being an undergrad again, it was like when someone goes to the right, all the molars and premolars are touching as they’re grinding. And that’s kind of what I probably remember from that stage.

[Michael]
Okay. So one, I’m glad you brought it up and that you could remember some of that until you’re being honest about it. Now, if you actually look at the definition of group function, it actually doesn’t name any teeth. So, I am one of those weirdos. So, the glossary of prosthodontic terms, which started in 1956, I have read every single issue up to the current one that just came out. So, there are about nine, 10 issues. So, prosodontist.

As a professional or recognized in 1947 by the American Dental Association. It took them nine years to figure out what the heck they were teaching because there were no terms and they weren’t defined. Group function wasn’t defined, I don’t think, until the 70s. I went back into prosthodontic terminology and what it says, and I actually, I actually printed it out just so, just so I don’t miss it.

And it says group function, multiple contact relationships between maxillary and mandibular teeth and lateral movements on the working side, whereas simultaneous contacts of several teeth act as a group to distribute occlusal forces. Now, you were taught the same thing I was by my teachers, that it involved a premolar and a molar.

That has never, ever once been written as a definition. It’s just more. It’s group. So that group could become a canine and first bicuspid, a three and a four. It could be a three and a one. It could be a three and a six. It doesn’t matter. It’s just the distribution.

[Jaz]
They could also be anterior group function, which I learned many years later.

[Michael] Past as Prologue: Learning from destruction  
Yeah. And that’s how I practice if I can’t. So canine guidance, someone, we look at these patients that have destroyed their canines. We’re like, oh, we have to give them back canine guidance. I’m like, why? They just destroyed it. They’re going to destroy it again. Past is prologue to destructive schemes.

You know that Janine and I have the largest retrospective clinical on wear patterns in the world that’s ever been done. We followed 386 people over 10 years. And there were patterns. And the thing is, over those 10 years, those patterns and that parafunction did not change pre ortho, post ortho, pre equilibration, post equilibration, even pre and post orthognathic surgery is one thing we have to clear up is we’re not going to stop them from doing it.

Pain Points: Focusing on the At-Risk Patients
So when you say which people need our occlusion stuff, it’s ones that are at risk. So if they are destroying, or if they’re in pain. Are there modifications that we can do to help them stop doing that? Ah, let’s just do this, Jaz. You’ve done it before. Okay. Second motor context. Sixes, fives, threes, ones. So, we’re going to take a finger. You too.

[Jaz]
Let’s do it.

[Michael]
Take your finger, Jaz. Okay. You’re going to take your finger. You’re going to go all the way back to your seven. Tap, tap, tap. Once, and only once, light is 180 p. m. Ouch! And stop.

[Jaz]
Uh huh. Yep.

[Michael]
Yeah. Got it? Okay. Take your second finger, your middle finger, go up to your three, your canine. Go tap, tap, tap. Once and only once bite as hard as you can. Yeah, good. What did you experience there in the difference?

[Jaz]
So not as severe as a molar and I could hold it a bit longer. It’s not very pleasant I wouldn’t want to hold it for any longer.

[Michael]
Okay, so let’s go to a third finger. Let’s go 2-1 and I’m going to go to my 2 1 because my implant and I could go-

[Jaz]
And I have resin bonded bridge in the lower anterior so I’ll pick a tooth as well.

[Michael]
You’ll be okay because you’ve got your soft thing there. So you can, so I’m going to go 1, 2, and 3. Bite as hard as you can. Bite, bite, bite, higher as you can. Ah. Everybody’s got one of those? So what you- you got your little occlusal love mark, that love bite right there. What we’re saying is when we hit on molars and let’s just go MIP, okay.

That’s a hundred percent. Molars were still at a hundred percent muscle activity. We go up to the canines, we’re at 70%, not 70 percent reduction. We’re still at 70 percent muscle activity. And then when we go to the centrals, the midline, we’re at 30%. So where does it make sense to have our disclusion? As far forward as we can.

Smooth Transitions: The Ideal of Disclusion
And what Peter said, what Dr. Dawson said was canine initiated disclusion with a rapid transition to a more anteriorized contact. And from us just biting on those three fingers, what that means is start on the longest, strongest tooth in your mouth, but you’re still at 70 percent muscle activity. So as fast as you can get up front.

And that is where we get crossover. So, when we cross over the tips of the canines, we want to have that smooth transition. So, the things that we want to do to help promote longevity is we want to reduce either the time that we’re in high muscle resistance or we want to reduce the angle that we’re in high muscle resistance because those are the two things that lead to stress and strain either on our enamel or on our ceramics.

[Jaz]
So in other words, the patient who has very steep cusps who is locked in is unable to move their jaw and is rubbing on their molars a lot while they’re doing it. That’s the worst form of forced attribution. that we could have compared to someone who’s got shallower cusps and it’s initiated by the canine and very quickly moves to centrals for example, just giving examples for the younger listeners, that will be a less stressful bite if you like.

[Michael]
Right. And the key word that you said, or key phrase that you said in there, if they do it, because a deep bite and long, steep guidance doesn’t mean anything in and of itself. It matters the intensity that the teeth are brought together.

Occlusal Schemes: Debunking the Malocclusion Myth
And you’ve seen that. You went back a little while ago and you were talking about TMD and occlusion. It is the University of Florida looked at all different occlusal schemes and there was absolutely no relationship between malocclusion and quote unquote proper, by the way, proper occlusion is an orthodontic board exam requirement.

It’s not a health requirement. So what you’re saying is when they’re hitting a canine, 70%, and a molar, 100%. So they’re really distributing 100 percent muscle activity between a canine and a molar. So when you go to a canine and a central, now you’re at 70%, but you’re distributing between two teeth. So, long and steep off the canine and then when you get up towards the incisal edge That’s where you’d have unsupported enamel or ceramic and that’s where you want to have that transition to a more anterior as contact I think we’re talking about that clearly is this because this is your playground So I know some people are going to see all our hands and some people are just going to be listening.

[Jaz]
And I think this is where people can get a bit lost. So if you were to speak to me when I was just freshly qualified and I hadn’t been bitten by the occlusion bug and the fascination and if I had been seeing a patient and I was as part of my examination doing the occlusal exam and I was checking for the excursions and I was seeing that, whoa, there’s a lot of back teeth rubbing here, that this isn’t what the textbook says, then sometimes we can write or maybe I would have written back then that, ah, this patient has some occlusal disease.

What’s your viewpoint on someone looking at a patient’s occlusion and seeing that, ah, there’s a big deviation to what the textbook says, and therefore thinking, hmm, as part of restoring the caries, fixing the perio, we also have occlusal disease because it doesn’t match the textbook. Because that for me is a very dangerous sentiment, but it goes back to exactly what you said with the glasses.

CR Reconsidered: The Healthy Majority
The way I think about it is, if 97 percent of us, right, or maybe even more, and depends on which study you see, are not in a fully seated position, are not in centric relation, then secondly, the 97 percent is the healthy and normal, it’s the 3 percent that we idealize and we aim for, the ones centric relation, that are the diseased ones.

When that penny dropped some years ago, I was like, wow, okay, fine. So maybe not everyone needs to be in central collation. So what would you say to that young dentist who’s looking at these occlusions and thinking, whoa, okay. As well as treating the caries perio, the bite is wrong. Therefore, I’m now going to do some dentistry to idealize the bite for this patient.

[Michael]
But if I could put that on hold just for a second. So when you talk about CR, centric relation, let’s change our brains. Like, let’s just talk about these words. CR is a joint based position. It is defined by the joint, nothing to do with the teeth.

MIP, maximum intercuspidation, is completely defined by the teeth and has nothing to do with the joint. We’ll get to CO later. So if you are in the most seated position, everything is anterior guidance from the joint. So the whole purpose of having centric relation, it’s not a health position. It’s not a pathology position.

The only people that are in CR all the time are dead. They’re not moving. But all of the rest, we’re not static beings. We move all over the place. So now going back to your young dentist question. I think we need to start looking at how to-

[Jaz]
Let me give you a clear example. Can I give you a clear example to maybe channel this in? Something you taught me in Stockholm, right?

[Michael]
Yeah, yeah.

[Jaz]
You said we look at someone’s occlusion and at dental school someone taught us that, ah, that’s a non-working site interference. And therefore, we think, oh, this cusp shouldn’t be touching when the patient’s going to the right. Therefore, I should get my bur out and maybe start drilling it.

Or maybe this can now go as a diagnosis entry saying, oh, there’s a non working site interference. This is bad. Well, how can we send a message out to everyone that actually just because it doesn’t match the textbook doesn’t automatically mean that it’s disease or that it needs treatment. Okay.

[Michael]
You’ve given me PTSD. You’ve used the interference word about 15 times. So we’re going to, you promised me we’re going to get back to that cause that’s what we have to talk about. I’m starting to stutter. All right. So what I’m going to tell those people is stop looking how people move. Start looking for signs that they do that movement.

Diagnostic Vision: Seeing Beyond Occlusion
Stop looking at how people move. Start looking at if there are signs that that is how they move. So, what I mean by that is it doesn’t mean put paper on there, or film, and have them move and see red and black marks. What I want you to do is just use your eyes and your brain and say, is there wear? Is there fremitus?

Is there mobility? Because all of those things are symptoms and signs of that motion pathway. Because you can have people with absolutely perfect occlusion, perfect canine guidance transition to crossover, and they are in miserable pain because they have such high intensity when they do that. Then you have these people that have a crossbite every other tooth and their curve of speed and Wilson are just like, and their occlusal planes are like up and down like merry go rounds.

And they still have all their parakamana. They still have all their mammelons, and they have absolutely not a wisp of wear anywhere. And you want to correct that? What are we correcting? Is, I think, one of my favorite things that Gary DeWood said, and he’s one of my mentors from Panky, is he said, I’ve equilibrated hundreds of patients in my career.

Half of them probably needed it. The problem is I don’t know which ones because when I started doing it, I was just doing it because they had eyeballs and I wanted to give everybody glasses. We have to have a reason, not only for our treatment, but for our diagnostics. Is there wear that needs to be addressed?

Is there pain that we have to figure out where it’s coming from? Are there functional or aesthetic concerns? And I think too many times we go into all of these little boxes of diagnostics, especially in occlusion, when there’s absolutely no reason to do that, unless there is.

[Jaz]
Unless there is. Absolutely. And I’m just thinking of scenarios. And I think sometimes by pitching different scenarios, we can bring these concepts home. And I’ve got a few more points to make thereafter to try and make this all go around in a circle and make it fully tangible. But canine rises, for example, right?

They’re a treatment modality. They’re a technique to give someone back their canine guidance who had lost it. Do you use this technique as a standalone in your practice? Have you used it in the past? And if you answer that one first and then we’ll go from there. So canine rise, I know lots of clinicians do, but where does this fit in into your practice?

[Michael]
Okay. So if someone has lost canine guidance, I have to look, what is their goal? Do they have an aesthetic goal or functional goal, or do they just not want to break stuff and make it worse? So just purely putting back canine guidance, the two components of introducing shear forces are increasing overlap.

Rebuilding with Purpose: Beyond Aesthetics
So if you’ve lost canine guidance, your canines are short and you put them back, you’ve actually increased overlap, which increases your time and disillusion. So if they broke it off, what are we doing different to make it not break off this time? And that’s where I’m going to look at how can we move things forward.

And when I say forward, I mean towards the ones. And that is canine initiated at 70 percent muscle activity towards the ones. And this will always come to me when I’m doing some sort of smile design. And I don’t do all full mouth rehab. Sometimes it’s just the anterior floor and maybe fixing the lower incisal plane.

So this is probably one of the most typical cases. Two most typical cases that I’ll see is we’re treating the 2-2 on the upper and we have a worn super erupted plane on the lower. So you have the stepped occlusion. So what I want to do is how do I want it to look? So how do I want the 2s and the 1s to look?

And then how do I get that in transition of canine guidance over to the ones? And that is usually by doing some corrections on the lower occlusal plane. Now, the other one you kind of talked about, Jaz, is what about people who are not class one? So, what if you can’t even get canine guidance? Do you make the canine like five times as thick as it is tall?

No, then you’re in group function and the group function might start on the four. And then you go from the four to the three to the one. What about the two, Mike? Yeah, good question. The two, let’s just skip those. That’s a weak, wispy two.

[Jaz]
And for our Americans, obviously you’re making it British for our British followers, but the lateral, laterals. Yes, yes.

[Michael]
Sorry, sorry about that. So in a class two, you might start on the first bicuspid. Then go to the canine, skip the lateral, and then go to the central. Why do we skip the lateral? Because it’s this teeny little wispy tooth, and if you’re coming off 70 percent muscle activity on the canine, and you hit the two, that’s where disaster strikes a lot.

[Jaz]
And I like to actually use canine rises more in the following scenario. When someone is exhibiting a little bit wear on that lateral incisor, for example. Right? And when they go into excursion, just like you said, you observe with your eyes that actually the wear sets are matching up. Sometimes the role of the newly placed canine guidance or canine riser or the canine disclusion is actually to give you that space to restore that lateral and lengthen it so that it’s not going to be crashing in.

And so sometimes it’d be strategically used like that. But the kind of point I want to make to young colleagues is don’t look at someone’s occlusion and see group function and think that that’s a disease and therefore that you need to give everyone back kind of guidance.

I think we did, we’d covered that in that sense. But here’s another way to think about it. If and when we are doing full mouth cases. At this point, when you are now designing things in WAX, and you kind of mentioned already we want to be mindful of past this prologue, what did they do before, and I love that saying of yours, but when you are designing the occluding scheme, do you have like a goal, occlusal goal in terms of, I would like to give this patient canine guidance because you kind of have a bit more freedom in wax.

Obviously, we’re limited by their skeletal base. But if you had a choice that you could, I should give this patient group function. You open up the articulator. You’ve got a bit more space now, or you can prescribe canine guidance. Which one are you doing? And why in this kind of a case where you kind of have committed to a reorganized case, i. e. we are committed to doing some comprehensive dentistry involving several teeth at least in some maybe full arch.

[Michael]
Okay, so I’m going to take that as the step back to your simple case of their clipping on their incisor, because that can be in the limited case or the full case is my question is why are they clipping on that lateral incisor?

Did they lose canine guides or did they never have it? So let’s, okay, simplified. Some people call this the Melker’s mantra. How do you want it to look? How do you make it fit? How do you mitigate threats? So in a full mouth case, and I’m going to make some assumptions on a full mouth case that there is going to be some aesthetic component to it.

Even if they don’t want cosmetics, they don’t want me to make their teeth look worse. Except for one patient. That’s a long story. Most people don’t want you to make their teeth look worse. So, how do you want it to look? That’s going to be your uppers. How do you make it fit? You’re going to think that I mean dots in back and I don’t.

How do you make it fit? The next thing I want is edge to edge. Because that’s the end point in parafunctional control. Why do I want my upper centrals and my lower centrals to be edge to edge? Because that’s in compression so the two forces that we have in dentistry that threaten our success and our restorations and our reputations are sheer and compression. So everything works better in compression.

Denton and now I’m sorry, dentine, Denton for the Americans, enamel, compositor, composite ceramics, gold. It doesn’t matter. Everything works better in compression. So sheer is where we’re at with the canine. So how do you want it to look? Then how do you make it fit edge to edge?

Then how do you mitigate is bringing it back from edge to edge to MIP. And what that journey backwards is actually that muscle stroke that actually pulls the condyle to a seated position by the masseters and the temporalis being at high level of activity. So if I got two esoteric there for you, Jaz, what do I want my full boss to look like?

I want one single at least one single contact point on all my back teeth, premolars and molars, on a flat receiving area. You’ve heard me talk about landing pads. Then, what I would like in the anterior is canine initiated disclusion, if possible. Why? Because it’s the longest, strongest tooth in the mouth and it can take the abuse.

Up until it gets a little bit past the cingulum. Past the cingulum, you still have dentin behind you, whether you have ceramic or enamel. Once you get past your core material, and that’s old school because we have so many monolithic emaxes and zirconias, but once you get past the dentine underneath supporting that, you’re actually at shear and about the incisal quarter. So that’s when I want to start transitioning anterior. So canine initiated with a smooth transition to a more anteriorized contact that’ll be in compression. And so that, that’s kind of my thing.

[Jaz]
So I knew you were going to say that because I’ve done your programs. I’ve learned so much for you and I can’t wait to get out of you. And really the point I wanted to make for all the listeners here, right. And just want to untap a lot of things that Michael’s taught me. over the years. It’s something I’ve also reflected on in the orthodontic circles, which is basically, when I started to learn orthodontics, I did a diploma. I found that no matter what patient came through, the way orthodontists make a problem list is, okay, they want everything to look like a class one on a model, basically, right?

Canines in class one, right? And so they find everything that’s wrong. About this patient that’s not class one and their basic treatment is what can we do to get them into a class one, right? So it’s kind of like a rubber stamp and they put it on and this is the end goal every patient must look the same and this is the truth.

I feel as though this is what orthodontists do. This is this is how the pressure works Not all orthodontists obviously, but class one is the goal class one canines at least is the goal. Now the way I see this being applied in terms of occlusion and canine guidance is for our general patients. You know how Peter Dawson, he’s Dr. Dawson. He’s a general patients and complete patients.

And they’re two different things. And our general patients day to day who generally their things are working. Also, Frank Spear. I love what he says. Quiet muscles, noisy muscles, right? Lovely saying if someone’s generally got an occlusion that’s working for them.

And yes, if you look check with paper, just like you said, Mike, they might have these non-ideal features. Whoa, whoa, whoa. Non-ideal. I mean, according to textbook, they might deviate away from that textbook. I’m not going to say the I word. Okay.

[Michael]
Thank you.

[Jaz]
They might have these non-ideal features about them. But because generally it’s working, they’ve got quieter muscles and they don’t have a need for treatment. However, when we have the opportunity to give the patient what they want. So Michael’s first question always they want their teeth to look better or they’ve destroyed their teeth. And we are now have a blessed opportunity to they’ve entrusted us to treat them.

Now, we do exactly what Michael said, which is, how do you want it to look, okay? How do they fit together? And the last one is mitigate the forces. And a accepted, one accepted occlusal scheme is the one from the textbook. Just like the orthodontist go for class one, this is a example of applying a mutually protected or minimally stressed occlusion.

So I guess there’s a roundabout way of saying is that what I learned and the conclusion I came to is that the ideal occlusion and the textbook, we cannot apply that to our day to day dentate patients who have an occlusion scheme that’s generally working for them. We do have to pick up the book though, when we have an opportunity to completely redesign everything. What do you think about this way I’ve kind of like philosophized over this?

[Michael]
I like it, Jaz. There are a couple of points in there that brought it together for me. One when you talked about the orthodontist getting a rubber stamp, that’s literally what they’re getting because that was their board requirement. That was their board requirement for the cases.

[Jaz]
The midlines had to be perfect. They had to have the canine in exact position. And that was the par score. All their metrics are based on that.

[Michael]
Exactly. And so second one is there are restorative dentists that actually do that same approach. As I say, I have to do everything. So I have to control the occlusion. So instead of saying ideal and going back to the textbook and say, we need to do ideal. How about we change that word ideal to appropriate? Because the appropriate care can be limited. Or vast in scope, an application depending on the patient’s needs. And now I need to go back to the I word. So what is the I word? Yeah, say it. Say it out loud.

[Jaz]
Interference. Interference.

[Michael]
What does that word infer?

[Jaz]
It means we need to do something about it is a bad thing. Negative connotation.

[Michael]
Exactly.

[Jaz]
Pick up the bur.

[Michael]
Exactly. And that’s why I have a huge issue and I know you joke with me about it and a lot of people do. I have a massive problem with that word because it infers that it needs to be corrected. So an interference to what? A, because group function can be interpreted as interference, but if the group function is appropriate for that patient, it’s not the interference, it’s the optimal occlusal scheme for that person.

So I hate that word. I will never stop hating that word. And I’ve been in therapy over that word. So thank you for letting me get that off my chest.

[Jaz]
Well, now everyone knows why Michael hates the interference word. And just generally speaking, One thing I was taught actually was, if you If someone has that feature of their occlusion, then perhaps we should refer to it as a non working side guidance.

Not a non worker side interference because for that patient it’s appropriate for them. It’s working. They’re not breaking anything. They don’t even have wear there. They don’t have any issues perhaps and a lot of our patients don’t have any issues. They have those features, but they don’t have any issues. So perhaps for that patient it’s appropriate to name that a non worker side guidance.

Whereas actually if there is a significant problem being created by having this type of relationship in that patient’s mouth, maybe then in the selective cases, we may be able to use that term because in that patient you are planning to treat that or correct that so that we can, going back to what you said, anteriorize things, reduce, dial down those forces, because this is a destructive patient, for example.

[Michael]
Okay, so let’s talk about. working side contacts posterior to a canine. Okay. So that’s the traditional group function area. So when is that a problem? So that can be a problem. If they have muscle issues on that side, their teeth look fine. That can be that they have wear or fracturing or chipping on those teeth.

Then it’s an issue. Now, the third one, and you touched on this almost at the beginning, but we’ve talked about periodontium. What if the teeth look fine? They don’t have any pain. They don’t have any chips or cracks. What’s the other one I’m going to worry about is fremitus. So ink lies to you like, can we swear?

[Jaz]
Yes.

[Michael]
Like a bastard. Ink lies to you like a lying, cheating bastard. And because if you put ink over there and you’ll see one thing, but the teeth might be moving. You’re like, oh, this is fine. He has perfect balance, occlusion. What I do is I stretch my gloves, I turn my fingernails on the side and I put it against the facials of those premolars.

And when I have them, I don’t have them move to that side, I just have them power wiggle. And so, if I see no chips, no wear, no fractures, no muscle issues, but I feel fremitus, then those working side, and I’m going to call them contacts, because contacts without interpretation, it’s not a good or bad, it’s just an is.

So, if they have working side contacts on the bicuspids, And those bicuspids are inframedous and those are the teeth that will almost always be inframedous from occlusal. Oh my God. I almost said interferences.

[Jaz]
Overload.

[Michael]
So, from occlusal contacts, then we have, yeah, we have to go to the why. We always have to go to the why. Why are we looking? What are we worried about? Are we worried about breaking down of the system? That system can be above or below the gum line.

[Jaz]
And it’s good because you made this point about if you check with articulating paper, everything seems normal, but fremitus is sometimes overlooked because of that, because we see that, oh, the tooth looks healthy.

And of course, when we take a radiograph, we see that I’ve got very good bone levels and you think, hmm, what’s going on here? And you’ll see that once you change the occluding scheme for that patient, that quite often these teeth will start to firm up as a response to their new environment.

[Michael]
Absolutely.

[Jaz]
You can see why, Michael, that there never has been an episode that I’ve found on any dental podcast ever with this title of Canine Guidance vs Group Function because A, it gets people into, not us, but it gets people arguing and fighting. And in that spirit, I’m going to ask you now two naughty questions that could upset some listeners and viewers. So let’s do it. Okay. Number one, Michael’s nervously looking around, he’s getting his mask on now. Okay. Does Michael Melkers believe that abfraction exists?

[Michael]
Maybe.

[Jaz]
Me too.

[Michael]
Abfraction by definition, infers the defines the cause. So an abfraction is a cervical lesion that is caused by occlusion and occlusal flexure. So if you look at the work of Zakovich versus G. V. Black and all the way back in the day, actually abfraction versus non carious cervical lesion, go back into the 1800s. This is not a current argument. So, abfraction means the teeth are flexing and then we’re getting cervical notching. So, non-carious cervical lesion means there’s a notch down there, but we have no idea where it came from.

Or it does not infer causation. So, I am of the belief that I don’t know everything. And my sister would agree with me on that one, but I believe in multifactorial. You have acid, you have toothpaste, and you have flexure. Zakovich’s work showed that it has nothing to do with the stiffness of a brush. That the stiffness of a brush, hardness to softness, neither will affect enamel.

Then on exposed dentine, neither will affect dentine. You have to bring a dentiferous into it. So you have to have, bring an abrasive into it. So I am much further leaning towards this being a mechanical erosive than it being occlusal trauma.

[Jaz]
Brilliant. I just wanted to get that out there. And the second controversial thing I’m going to mention is, I’ve recorded some episodes with like amazing dentists, like Sandra Hulak, for example, teaching with Kois.

And recently when we saw Dr. John Kois at AES, he mentioned his very famous paper that he wrote, like the myth of anterior guidance. I’ve read that with great fascination. I use some principles from that, but essentially the point that I’ve seen him make before is, why are we checking patients in lateral excursion, because that’s not a functional movement.

And we don’t do that in function. I get it because just like you said, as well, parafunction is starts on the inside and goes outwards. Function is outside in. But where I am at the moment, I feel as though I’m just going to check for both and I’m just going to account for both. That’s my current stance.

Like, okay, I see what you’re saying and I see what the other camps saying and you know what? I’m going to try and make sure that things don’t clash together in function and I’ll check for parafunction and I’ll make sure that things are working harmoniously in parafunction as well. But my question to you, I guess, is, Michael, I just don’t know how you can get away with finishing inclusion and not checking the lateral excursion.

I just feel as though it’s something that is part of, it should be a checklist that you do. Because if there are these overlaps and time in resistance and high forces in resistance on a parafunctional patient and sometimes they may become parafunctional in the future, then we still need to account for this.

I just feel as though if we exclude that element, because some camps believe that only 1 to 2% of people are bruxo maniacs, and therefore we don’t have to check. This is much better just to check functional movements. I just don’t see that sitting well with me. What are your thoughts on that?

[Michael]
My first thought is that one of the worst things we’ve ever done as a profession is in fight. That is in fighting, not inviting, is fighting between each other is we are literally making all this stuff up and it’s theoretical. If it wasn’t theoretical, there would be far more proof to support either functional or parafunctional.

So, Dr. Kois, I have known each other for a long time and we shook hands and butted heads over the years on this. So. I think I agree with him in that one of the things that we check is lateral excursions. Lateral excursions is when the muscles are actually at their weakest, because the lateral pterygoid is overcoming the temporalis of the masseter.

And it’s actually the return stroke that that’s where the destruction is. And that’s why I said, how do you want it to look upper edges? How do you make it fit lower edges to upper edges? Because it’s the stroke back from there that I’m actually worried about. That’s where the masseter and temporalis.

And that is where you can really get confused between parafunction that is movement without purpose and function, which is movement with purpose. So functional movement with purpose is not just eating. It’s swallowing and it’s talking. So as I referred to before, Janine, aka Dr. McDonald, my wife and I followed 385 patients over 10 years in their wear patterns.

So that was not a double blind or even a single blind study because all of those patients were patients in my practice that needed splint therapy. They all ground. So this one to two or even 10 percent number, I think is, I don’t want to say garbage because that would be disrespectful, but I can’t think of another word.

[Jaz]
Can I just add that since, since you taught me to color in the dispense all those years ago with the sharpie, right? And I’ve yet to find that patient who doesn’t make that beautiful triangle shape in it with the apex force and so you think, hmm, surely if some a lot of these patients weren’t bruxist and I kind of got it wrong that everyone would come back without much on it. So in my experience to follow on from yours to add to what you yours and Dr Mcdonald’s work and I totally agree in terms of the evidence I see out there suggests that there is a degree of parafunction. Sometimes it’s less and sometimes more, but the activity is happening. It varies to each individual.

[Michael]
We have tried to stop parafunction by changing joint position, changing vertical dimension, changing dots on teeth and currently sleep apnea. And that’s actually going by the wayside. That we’re saying, even if we correct apnea, people are still bruxing, and my research shows that.

Now, when I think about this, when I’m doing restorative dentistry, what’s the harm in us providing and looking at that lateral or return stroke? We’re just covering our unknown basis. Now, I will bring this up, Jaz. So when you look at Dr. Kois’s work and the paper that you referred to, The Myth of Anterior Guidance, and he wrote that with Dr. Betsy Bateman.

In his diagnostics, he says, I believe it’s Dr. Bateman says. Aikman says is put some articulating paper between the patient’s teeth and then have them simulate a chewing stroke until their teeth come together. And they’re doing that to evaluate whether teeth touch. So they’re actually, with their words, this is in that article, is they’re telling people to chew until their teeth touch.

And then they’re saying that’s proof that teeth touch when people chew. But I mean, that baffles me. If you look at the work of Lundin and Gibbs and their chewing stroke cycles. Patients don’t touch their teeth when they chew. And if they do, it is a sign for them to be immediately disclued.

[Jaz]
And then eventually encourages the swallowing reflex. That’s the signal to the brain. Okay, now the food is mushy enough that we can go ahead and swallow. And those fleeting contacts there weren’t significant contacts of teeth. And they were fleeting. Little touches here and there. Rather than huge grabs and lots of rubbing of the cusps clashing into each other.

[Michael]
Yeah, I will layer this on there, Jaz. Whether you say it, whether I say it, whether Kois, Spear, Dawson, Bruchess says it, none of us should believe it. We should look for proof and put it through the filter. I remember being at the equilibration society at the 50th anniversary and looking at the legends, Tanner and Neff and Dawson and they said, we made all that stuff up 50 years ago.

There was literally no occlusal knowledge. We just made it up. It was a theory. You look at original Pete Dawson’s textbook, he self-cited a lot and then people cited him and then he cited the people citing him. So there was all this circular logic and Pete was a good friend. That’s why I keep calling him Pete.

Key to Dental Success
Dr. Dawson was a good friend, but they were very honest that they made that stuff up and that’s neuromuscular. Some of it worked. Some of it didn’t and the proof is fleeting patients are different You can have the exact same dentition and put it into you, me, Lincoln Harris and Janine McDonnell but if we have different risk factors, we could do different things with those dentitions so Lane Ochi, it’s not his quote, but he uses it.

What we need is a semi adjustable articulator, but a fully adjustable mind. We need to stop regurgitating what we were told. We have to come with everything. I think, God, that’s one of my favorite quotes is, we have to fear the present. Respect the past. If we are to provide for a safe future, it’s like always question, always be thinking, always be improving. And we should do that as a cohesive profession of colleagues that respectfully agree and disagree with each other. That’s how we’re going to move forward the best.

[Jaz]
And I just want to thank you for taking those two tough questions. And I think you did an amazing job with them. And if there’s one thing that people are chopping onions, they’re busy commuting and they’ve got this far and they think, oh yeah, there was a lot to take in and take home there.

Let me just remind you of a wonderful thing that Mike said is the occlusion that’s most appropriate for that patient. If we just start thinking away from the textbook and looking at our patient and say, okay, what would be appropriate for this individual? And then you’re 50 percent there to the answer.

If you actually just think in that way, I love that. You also mentioned about landing pads. And also I can tell you guys that what Michael has to teach when it comes to communicating with patients and the way to do co diagnosis along with Lane Ochi is well worth it for those things.

So I’m encouraging everyone. If you have the opportunity to be in London in end of July to come and see Dr. Lane Ochi and Dr. Michael Melkers lecturing together for the first time in London, I believe.

[Michael]
Yeah.

[Jaz]
I think that’s 27th and 28th of July. I’m going to put the link there. I really, really do implore all my audience who are in Europe, let alone London, Europe, if you’re in Europe and you can come, heck, if you’re in States, you want a tax deductible trip to London, and you haven’t seen Mike and Lane together before, it is really, or if you’ve maybe seen them before, like their stuff is worth repeating. So those kind of things. Are you excited for this trip to London with Lane?

[Michael]
I am so excited for this trip for a number of reasons is one, I love London. I think all the way back to the first time I taught there in 2005 or going back to the BDA. But Lane and I changed our program every single time is we are never static in this.

And even if it’s the same information, you’re going to hear it differently, but we have people coming from the Baltics. We have people coming from all over Europe. We have people coming from Sweden, Norway, Finland, as far away as Leeds. So we have a group, not only that I’m excited to share the information, there’s so many people in that room that I’m excited to actually meet for the first time and see you there.

Actually Jaz my sister, Julia, who you know, she and I have done some research together on radiation dosing. She’s actually going to be in the UK at the same time, so you might actually get to meet another one of my family members as well.

[Jaz]
Lovely. Now, I’m going to put the link there, but just can you give a flavour to these dentists of like, it’s a two day thing. It’s a two day, what exactly are you covering? Because I know it’s case planning, it’s occlusion, it’s communication. To give like a flavor to these dentists, because some of what we talked about is going to be covered. Like the whole landing pads, Lane’s told me, is a great concept. Generally thinking about case planning, phasing. But I want to hear it from you. What have you got in store for the dentists?

[Michael]
I think what’s really different. No, I don’t think so. I know what’s really different about our program is what was the kind of take home message, what matters the most in all these occlusal decisions that we’ve talked about?

It’s the patient, right? It’s the variant in patient. So Lane and I are going to provide the attendees with didactic information, but we’re going to support it with patient specific application. We’re going to go from single teeth to quadrants to arches to full mouths. We’re going to show you our words and our cases that fell apart.

We want to talk about why. And the way we get to do these cases is not by having occlusal knowledge, but actually being able to listen and communicate with our patients. So we’re going to blend communication, case planning, and occlusion together. How do you want it to look? How do you want it to fit?

How do you mitigate forces in patient specific applications and their stories? I have so many patients that are just so generous. They give not only their permission to share their cases. But their faces, their stories, their tears, and really what brought them to dentistry and why they needed us. So that’s really what helps us get the cases. It’s not knowing dots and lines. It’s actually knowing Dolores and Bob and Mrs. Bender. And you’re going to get to meet all of them.

[Jaz]
I just love everything about you and Lane, and Lane recently came on the podcast and he gave such amazing tips. Everyone’s been commenting on Protrusive Guidance. I saw you join recently. It’d be great to see Lane’s view there. And Lane’s been posting so many great diagrams and advice.

I actually emailed my entire list with some of the zirconia stuff that Lane very kindly has been sharing. And he’s been so giving and kind with his advice to the younger colleagues on there as well. So if you guys want to DM Mike on Protrusive Guidance and learn more from Mike and Lane, check it out there.

But I’d highly encourage you to check out that London course. If you couldn’t make it, honestly, this is something that was important to me in my journey learning from you. And now more recently, I know Mahmoud has learned so much from Lane. In fact, Mahmoud always says that over the years, he’s learned so much from you and Lane on Dental Town.

And he’s so excited to see you there together in person because obviously Lane wasn’t the