A Short Discussion on Occlusion Part 2

 In Part 2, we continue the conversation about the complexities of splints—when to use them, and how to know if they’re truly the right solution. 

We explore whether how to determine if your failed restoration is the result of parafunction, and take a deeper dive into articulators, comparing digital versus analogue approaches in everyday practice. 

This episode is packed with practical insights to help you refine your clinical decision-making and elevate your outcomes. 

To watch the full recording of the Occlusion course (held in Mackay 2025) subscribe to our online educational library correctdentistry.com

For more information about any of the CeoDental "in person" courses led by specialist Prosthodontist, Dr Michael Mandikos, visit ceodental.com.au

This podcast is brought to you by CORRECT DENTISTRY

Transcript

Dr Jill Fisher 0:10

Welcome back to part two of our podcast on occlusion. I'm joined with Dr. Michael Mandikos. Michael, we finished the last section talking about splints. And one thing that really surprised me towards the end of your program in Mackay, you spoke about you don't use splints as much as I thought you would. I think we have this idea that prostodonists are doing all of these veneers and full mouth rehabilitations, and you must be so paranoid that it's all going to break. So you must put a splint in. I think that's our rudimentary understanding of it. But you mentioned you're not using them as much as I thought you would. Can you comment on that?

Dr Michael Mandikos 0:45

I think I make about six splints, seven splints a year at best. So that's you you were listening. You're right. And I mean that could really be my practice. Um but I think the reason for it is like, what why are you making the splint? So there are people who have some tooth wear, and I think sometimes it's a little bit misdiagnosed. It's not tooth wear 100% from heavy broxing. So maybe they don't need a splint. Sometimes we see patients with some degree of TMD and they have some symptoms, and they may or may not be benefited by a splint. And again, you know, I mean, TMD is a a big nebulous topic, but I feel like it's it's best treated with with several professionals. And specifically I'm talking about a head and neck physiotherapist being involved. And so sometimes, again, a splint is not really necessarily part of that treatment. So um, like any practice, it depends what's referred to you and who you see. But um, yeah, I just as as it all comes together, I I don't make that many splints at all.

Dr Jill Fisher 1:47

So who are these six people in your practice? Why are they getting the splint?

Dr Michael Mandikos 1:52

Well, if you believe it, just uh just in the last week, one was a dentist who wanted a splint. But um, but they wanted the splint because they were aware of some nighttime parafunction. So they were aware of some clenching and grinding and and uh so they wanted the splint from the perspective that it might break up that clenching and grinding pattern and just give them some symptomatic relief. Of course, there will be the patient that you have to rehabilitate that has a very uh well-documented, well-defined parafunctional history. You know, they have destroyed their teeth and they've come to see you because they're a heavy bruxer. You know, I mean, again, that that's the sort of patient where you'd be foolish not to make a splint at the end of treatment. But, you know, out out of those categories, I'm not suggesting that they have to be dentists, but you know, out of the categories of the symptomatic person with classic nocturnal grinding, or someone who really looks like they're going to damage your restorations, or you've rehabilitated and then you're starting to see too early some some effects of parafunction. Yeah, they're they're really the the cases.

Dr Jill Fisher 2:56

So to play devil's advocate, you know, if your case fails, it's probably nice if you've given them a splint and you can say you didn't wear it enough. You know, is there some kind of insurance policy that feels nice to say to this patient, I I've spent a lot of time, you spent a lot of money, this thing's going to protect you. Do you feel that that's not real, or do you feel that they won't wear it, or there is just no value in that concept?

Dr Michael Mandikos 3:23

Yeah, now it's a little bit philosophical. All right. So the answer to that's philosophical, you're actually asking probably the the safest approach. And if you were to restore somebody with a with you know a lot of a lot of work, then obviously there's the potential for a lot that can go wrong. And if you were to provide a night splint for them and they wore it, then really the only time it could go wrong is when their teeth are otherwise coming together. And that was, you know, we went through some of those statistics in the program, but but people's teeth are rarely together. So unless they were daytime clenching because they were really stressed and focusing and whatever else, then in theory, you might have been able to set somebody up with a pretty poor occlusion and protect it with a night splint, and everything's fine as long as the patient feels like they're comfortable. Alternatively, you know, what I'm hoping we're doing most of the time is setting them up with a good, uh, even balanced occlusion with appropriate guidance. And the restorations, you know, if they're made well and and the occlusion's correct, if the patient's parafunctioning on average, whatever that is, then really not too much should go wrong. If a little bit of time passes and something chips or breaks prematurely, I guess the from my perspective, the skill is to say, did that happen because the restoration was defective? And you can't rule out defective restorations. If it happens again, now you might start to think, did lightning strike twice, or is there some bad parafunction occurring occurring here? And you look back at your occlusion and see if those teeth were isolated in occlusion. And so now you're thinking to yourself, okay, well, there is some parafunction going on and we need to protect. And that's probably the way that I do it. So back to you, you asked it nicely in an insurance policy. In the templated treatment plans that we have, there's a line that I either keep in the plan or I remove, depending on the patient, which says, because your wear was associated with parafunction, I think it's a good idea to make a splint. Alternatively, it's like, you know, I don't know that the parafunction was that significant. So at review, if we're seeing evidence of continued parafunction, then we're going to make you a splint. If at review you're just cruising along beautifully and everything's going nicely, we'll keep reviewing. And I do that because I know a lot of people don't want to wear a splint at night. It's not a lot, but it's a bit more into the cost and time of treatment. And uh that's yeah, it's a philosophy I've worked with for a really long time now. And touchwood's working well.

Dr Jill Fisher 6:00

So on that note, when you I know as a specialist, you get a lot of emails and questions from general dentists, and they they often ask you about their failures. Why did this happen? And it may be a crown coming off, an individual crown coming off, and well, did the lab do something wrong? Did I use the wrong bonding protocol? Had I not prepped the tooth correctly? But if you are observing failures or evidence of parafunction that's making you want to put that patient into a splint, are you talking about canine tips coming off or multiple units failing? Like how do you differentiate when you have a failure whether it was caused by parafunction or another cause?

Dr Michael Mandikos 6:40

Yeah. If you've got crowns coming off, you've got to suspect. I mean, in this day and age with the products that we have, you've got to suspect a technique issue. Either contamination of the critting surface of the crown, contamination of the tooth during bonding, or just, you know, the wrong material being applied the wrong way. I feel if you're seeing chipping of restorations, um, again, depends on the restoration, but you you start to fear more that it's it's tooth clashing. And if teeth are clashing, why are they clashing? Are they moving past each other and hitting each other the way you expected because that's how you set up the occlusion? Or is it totally unexpected, in which case you didn't set up the occlusion well? Or, you know, when they parafunction, they really find some eccentric positions that you weren't expecting. You know, the the chipping is probably more the chipping fracture is probably more the clue towards parafunction without a really hard and fast rule.

Dr Jill Fisher 7:36

I did see an interesting question that was posed on one of the dental forums only last night, and it and it was around a chipping restoration. Do you ever repair these things in the mouth, or do you feel like that's a fruitless exercise? If if, for instance, you had a crown in a parafunction, evidence a patient with evidence of parafunction, you feel like you've done everything right, but they lose a portion of their restoration. How are you handling that in the clinic?

Dr Michael Mandikos 8:05

It's it's always um tooth-specific and how big the fracture is and where it is and how much it compromises the restoration. And is that restoration one of multiple that completes an aesthetic result? And replacing one is almost going to be impossible to match. And, you know, so so sometimes your hands are tied and you want to totally replace the restoration because, you know, it's a marginal ridge that's gone, we'll say, or it's opened up a food trap where it's broken. Other times it's more of a cosmetic chip. And I think if it's more of a cosmetic, you want to do everything you can to keep the crown intact because it's fairly new, it's it's well bonded, removing it's going to damage a lot of tooth structure, it's a lot of effort, there's the matching issues. So I think um pending how it presents, I'd be just as happy to try to repair it as opposed to replace it. And there are just a few instances where repair doesn't mean adding, it could even just be reshaping, rounding something. Um, you have to be pretty lucky if if the break is like that and you just smooth things off. But yeah, somewhere, somewhere between the two, pending how they present.

Dr Jill Fisher 9:12

And just going back to splints for a moment, I know that these questions are probably shared by a lot of my general dental colleagues. So if you'll indulge me, you mentioned that you don't tell these patients to wear their splint every night.

Dr Michael Mandikos 9:26

Yeah.

Dr Jill Fisher 9:26

What is that about?

Dr Michael Mandikos 9:28

So the the evidence that that I'm familiar with, which goes back some years, I suppose, um, was that the introduction, well, I mean, first of all, it's it's still probably fairly fair to say that I I'm not sure anyone can 100% tell you how a splint works. Uh, we have some good theories and some evidence to support the the theories. So with with that and with your experience comes a little bit of your philosophy and occlusion. But the evidence that I'm referring to is that, you know, for for the majority of people, you give them a splint and it's going to interrupt their bruxing pattern if they're doing some nocturnal grinding. But after a while they get used to it. And so being able to change their occlusion regularly almost stops their body from finding a pattern of being able to brux. And um, you'll have to forgive the looseness of this description. But it's almost like you're confusing their brain. You know, they go to bed tonight and um they've always had no splints, so they put their teeth together and away they go, they start grinding. But tomorrow you give them a splint, they put it in, and their brain puts their teeth together and says, Where are my teeth? I can't feel anything anymore. There's something in the way and it doesn't know what to do. And if you leave that splint in long enough, they get used to it and they start to grind on the splint. So you take the splint out for a couple of days, and there's a few days where the brain's confused again and doesn't know where their teeth are and what's happening and doesn't grind until you've left it out long enough that they start grinding again. So if you were to think of it as simply as that, it it seemed to work really well over the years to have people use their splint on what I loosely refer to as an alternate night basis, and that is in for a few nights, out for a few nights, in for a night, out for a night, you know, in for a week, out for a week, but but no real pattern. And use it a bit symptomatically. A lot of people that have a splint will will tell you, oh, I've got to be wearing my splint tonight, you know, because they know they're in a period where they're grinding their teeth more. So they almost can manage it. And and all I'm trying to say is the rigid dogma of saying, here's this splint, then you have to wear that every night for the rest of your life, I I I don't really agree with. And and I don't know that people really comply with it. And I think to a degree they probably naturally fall into this alternate night use.

Dr Jill Fisher 11:50

Yeah. We spoke before about the way you adjust a splint and how it is quite a detailed process. It's time consuming. Um, obviously you have to charge accordingly if you're spending a lot of time with this adjustment protocol. If you're not wisened up on your protocol and you've been prescribing splints for some time and it's a little bit more rudimentary, are we harming people?

Dr Michael Mandikos 12:16

Well, now it's my turn to play the devil's advocate, I suppose. Um as I said in the lecture, we went through um just a little bit of material. So it wasn't a heavily scientific papered lecture, but I highlighted a particular paper where different designs of splints were all equally effective at treating uh TMD symptoms in that parti particular cohort of patients. And I pointed out that, you know, that that paper disappoints me. As someone who's trying to, you know, in my mind do something fairly accurate and fairly pure, it was like, well, it's almost, it's not implying that a sloppy splint is acceptable, but what it's saying is if you've got a splint with some different occlusal aspects built into it, and if it's, you know, just a little bit subperfect, it it probably is still going to help with symptoms. But that's what the paper was talking about. It wasn't talking about, you know, potentially long-term use. And so to play the devil's advocate, if you were to make a splint that, for instance, didn't cover all of the teeth, didn't make even contact with all of the teeth, then over a period of time you could elicit some bite changes and you know, over-eruption of certain teeth, and you know, that in itself may then interfere with the patient's bite. Um, whether it's so significant that it causes them symptoms or causes, you know, deleterious effects on their aesthetics, you know, I don't know. But but um the safest thing to do is to make a well-fitting, well-balanced splint.

Dr Jill Fisher 13:41

Right. I want to ask you a controversial question, if that's okay. And I hope you're comfortable answering it. You spoke about your mentors in your training and some of these amazing names. You mentioned Norm Mole earlier, and obviously your dear friend Harry Hughes, who's no longer with us, was such a great mentor to you, personally and professionally, and and he had his mentors in Ramford and Ash.

Dr Michael Mandikos 14:10

Yeah, really.

Dr Jill Fisher 14:11

And I feel like perhaps the education we're receiving in modern-day dental schools isn't to that same level. I don't mean to denigrate the wonderful education that we've had, but I feel like you've spoken about these grandfathers of these topics and how they had such evangelical opinions on these things. I feel like some of that's been lost in the system and and we're learning a watered-down version of perhaps what you and and your mentors learnt. Do you have an opinion on that?

Dr Michael Mandikos 14:48

Of course I have an opinion. Um, I think if you if let's just keep it with occlusion. I think in the course, my my goal was to uh help the audience understand that that it was likely that they had a a very confusing education in occlusion, or they may not have had very much occlusion. And as the hands went up, that you know, there were some people that had a couple of lectures in occlusion, which is which is really remarkable. And given how significant it is in dentistry and in reality how uncomplicated it is if you understand the bigger picture, it's really a a blight, you know, on the profession if if graduates can come out without a fundamental understanding of occlusion. And you're right, probably, you know, in the current era, you know, there aren't too many names around that you would associate with occlusion and the precision of occlusion, certainly not in Australia. You know, internationally there's there's still people that that relate to that, but you you do feel like there was a golden ear of occlusion. Now, that doesn't mean that all of those concepts are correct. And that's why we, you know, we spent a fair bit of the program discussing what concepts were there, what might have been good and what might not have been good, and where we come to in terms of a modern occlusion. But without some of that passioned teaching and um and and the a little bit of history so you can understand where you are today, and a little bit of theory so you can validate what you're being taught today. Without those things, you you can't understand anything, let alone the topic of occlusion. So so yeah, I do I do lament that it's probably not taught very well today, and and in some instances, maybe not taught very much at all.

Dr Jill Fisher 16:28

There was a lot of content there in Mackay, and as I mentioned before, that program is available to watch on the correct industry website. So do look it up. But Michael, for the people that weren't there and for the people who've listened to this podcast episode with their coffee not a wine, and they feel like they need a wine after talking about all of this stuff, if you could just crystallize the topics or what are your pearls of wisdom for people like me, general dentists working, seeing patients every day, who has a fair understanding of it but looks to you as our mentor in these difficult topics. How do you crystallize this topic in in a few moments? What do we need to know?

Dr Michael Mandikos 17:13

What do we need to know? Again, I think if someone has the opportunity to to watch the full program, it puts it into context. But I I think a few times during the day, I actually use these words. I said, in reality, if you just want a bullet point list, this is this is the list of things to know. This is the list of things to do. And it's pretty short. But if that's all we tell you, it doesn't help your greater knowledge. Because as soon as you see something that doesn't fit into that short list, you don't know what to do because you don't have the greater knowledge to understand it. Or if somebody presents an alternative, you don't have the knowledge to assess whether it's truly an alternative or just another fad that's coming and going. And I want to say that because the moment you summarize something, you know, it's I'm I'm happy for people to work with the summary points, but not to think that that's it, you know, that that's everything. But uh I think we could summarize that despite all of the concepts of occlusion, there's three occlusal schemes that we use in modern dentistry that are evidence-based. There's an occlusal scheme called a bilateral balanced occlusion. It's essentially reserved for complete dentures. Then there's an occlusal scheme called group function occlusion. And in that scheme, all of the teeth meet together evenly, and when the person moves into their excursive movements, the disclusion that occurs comes from a group of posterior teeth on the working side. So that means, you know, typically, or by definition, it it would probably include the canine, go right back to the seven, but but typically it probably means canine, first, second premolar for most people. Then we have a canine-guided occlusion, which again involves a nice stable, bilateral, simultaneous contact of all teeth and occlusion. And the disclusion this time is primarily from the canine protrusively and laterally, but it can also be with the central incisors protrusively. Those latter two types of occlusions are called a mutually protected occlusion. And the importance of that concept is that posterior teeth in guiding contact can have much more force put on them than anterior teeth, and they are much more subject to fracture and damage because of that force. So the anterior teeth come together and provide the disclusion of the posterior teeth. When the person clenches and bites, the big broad posterior teeth come into contact and take those axial loads and spare the more delicate anterior teeth from those vertical loads. Therefore, the posteriors protect the anteriors and the anteriors protect the posteriors, and we have a mutually protective occlusion. There's one lecture of an occlusion program in undergraduate, which, you know, is sometimes not taught that clearly. When you understand occlusion as simply as that, you have to think about how you put things together, and that's articulation. And when we articulate things, we often think of an articulator as an instrument to put things together. Then you have to ask, how do I put things together? Do I put them together where all the teeth just meet? Or do I put them together in this conceptual position of centric relation? And in this podcast, we we probably can't talk about the importance of centric relation and how to use it and how to do it. But suffice to say, when you're treating a patient, you have to understand, am I conforming to their existing occlusion? And you and I, I think we have most of our teeth. We bite together, our teeth come together, it's a stable, comfortable position. There's no need to change it. So if I had to do a crown on you or you do one on me, we're going to do conforming occlusion. And so there's no need to change anything. So when we have a conformative approach to occlusion, we just want to put the patient's teeth together. Whether you take a cast and put it together, or whether you take a scan with the teeth together, you've got the teeth together, and that is all you need to articulate. So you can use a plain line, average value, uh simple hinge articulator to do that. The moment you want to change a person's occlusion because you're doing more than one tooth, or you've got evidence of damage on multiple teeth, and you have to change how their teeth come together and scoot past each other, we're talking about movement. And when we have movement, we've got to be able to work with the restorations out of the mouth and bring them back to the mouth on an instrument that can simulate the movement. And we talked about different articulators and how to program those articulators and what their limitations are and what their strengths are and where they fit in different cases. But the moment you're talking about changing the bite or creating some movement, you need an instrument to do that. And of the four groups of articulators, ideally the semi adjustable articulator is the one that you would use. And if you can do those things, they're the fundamentals of occlusion. Then there's how to program something, you know, there's when you'd use CR and when you wouldn't, but I mean I mean, they're the fundamentals of occlusion. There's not a lot more to it. So realistically, yeah, you know, occlusion could be taught in a series of lectures in one semester at dental school and then employed as you go to clinic by the same person who teaches it so that they use the same terminology. So you don't think they're now talking a new language with new concepts. Yeah. That's that's that's my bullet point summary.

Dr Jill Fisher 22:21

There was a lot there.

Dr Michael Mandikos 22:22

Yeah, it was still a fair bit, but but you know, in reality, it's not that complicated.

Dr Jill Fisher 22:27

A lot of the things you mentioned when going through your bullet point summary was quite analog. I know you had, you know, you could have a scan, but there was the discussion about conformative occlusion and holding casts together or using an articulator of some type. What if you're in a fully digital practice? Can you can these digital systems articulate in the way that these other engineer-driven desk articulators can?

Dr Michael Mandikos 22:58

If you um if you want to hand articulate because you're going to conform, the most accurate thing you can do with two casts is to make sure that they're accurate casts, scraped free of any positives, little bubbles, and hand articulated together without a byte record. That is the most accurate thing that you can do. And if a digital scan can't pick up the two arches in that same position and recreate that same static relationship, then digital dentistry is nothing. So, and and I believe that you can do that very accurately with digital dentistry. So, really, the question then becomes when you move from a static position to something dynamic, can digital dentistry allow the casts, or in this case the digital scans, to move past each other with the same simulated accuracy that an articulator can. And there I can't speak from experience. I I know that there is software to essentially create a digital articulator. And maybe there's some people listening in the audience who say, yes, you know, I've I've used this and and I believe it works really accurately. And even if it is accurate, which, you know, hopefully it is, and if it's not, it's getting to become more and more accurate. But even if it is, if you don't understand the principle behind it, there's no point in having some software that says, I'm simulating this movement if you don't know what you're doing. So it doesn't mean that you have to have a fully analog approach and then transition to digital. It just means you have to understand it. And when you understand the movements and what they're doing and what causes them and what the consequences are, whether you work on a digital articulator or an analog articulator doesn't really matter.

Dr Jill Fisher 24:31

Michael, thank you.

Dr Michael Mandikos 24:33

You're welcome. That was a lot of information. Oh well, it's always good talking. Like I feel, Jill, you you, you really um you know the questions people want to ask. And uh, you know, floating around the back of a room listening and making notes is one way to certainly capture it. And, you know, we're always grateful when an audience takes time to send their questions in so that we can, you know, use them in a podcast to make sure we address them.

Dr Jill Fisher 24:54

Yeah, please do send through your questions. A lot of the discussions that Michael and I have, and they've grown into entire two-day hands-on programs, have come from a simple question that's been asked in an email format or in in the back of a room. So do send them through. You can send them to info atceodental.com.au. And please have a browse through our other programs on the Correct Dentistry website. There's a lot there. Um, we have always room for more topics. So please let us know what you're interested in. And thank you for joining us. Thank you, Michael.

Dr Michael Mandikos 25:31

Thanks again, Jill. Great talking.