again my name is Dr Leonard Hess I'm The Clinical Director here at the Dawson Academy thank you for joining us and so we're going to do this quick little webinar here and as you probably can imagine we're talking about a fairly daunting topic to try to do in an hour so what my goal here is to hopefully get you to think about vertical Dimension or the instances where you need to change vertical Dimension and give some little tips and tricks to hopefully keep you out of trouble and if you see a patient to where you might think that I have to change vertical Dimension give you some things to think about as we do this so you know the the reality is Dr Dawson he used to always joke that vertical Dimension is one of those topics that dentists just love to make it so hard you know these are we have about I think three or four things in Den industry that we love to make it as difficult as possible on ourselves and um and typically what we need to do is just simplify things break them down into their individual components so that we can understand these things better you know that you think about who do we take study models on and we're not really ever taking study models on people that have really good teeth we're usually taking impressions of people's teeth that is are usually really poor and then we throw them on an articulator and usually if you hand a dentist a complicated looking case on an articulator you know the first thing that they usually start asking is oh my gosh what are we going to do with the vertical Dimension are we are we cracking the vertical Dimension open are we maintaining it I think I need room to restore and the reality the reason why we get so trapped into these situations doesn't mean that they're difficult questions we just need to know what is the right question to ask when we're looking at a case like this you know if we think about it in Dental School school we were really taught in dental school to treat problems related to bacteria we were taught to diagnose periodental problems we were taught to diagnose uh carries but we weren't really taught to analyze people that have gotten their dentition in such a state that we need to think about opening up vertical Dimension and this is such a valid topic you know even when we're working on natural teeth but this is an an enormously complicated topic when we start talking about people that have loster dentition we're starting to talk about putting Allon X restorations in there full Arch Restorations over implants and vertical becomes very important as well so the other thing that Pete used to always say about vertical Dimension this a great quote from him if the video must be altered to the most conservative dental treatment possible to achieve the optimal aesthetic and functional results and that's simply of the occlusion and the system that the teeth are functioning in there will be adaptation as we go through these types of cases and so really when you think about it opening up vertical Dimension is really easy but the question is do you understand why you're opening up vertical Dimension and that really becomes the hard thing to manage and when you look at somebody that has a case like what you see on the screen here obviously you see somebody that has a severe breakdown of their dentition and most of you realize you're not be a you're not supposed to be able to look at anterior teeth and look through them like a window you know there's a tremendous amount of three-dimensional tooth structure that has been lost in a situation like this and a lot of times these patients come in and they think that they just want to fix up their party teeth they just want to those maxillary anterior six or eight teeth ones they show the party that's what they really focused in on and a lot of times patients and want to try to dictate treatment to try to do things as cheaply as possible and still get what they perceive as the outcome that they're looking for but these types of cases if we don't really understand what it is that we're doing become complicated of materials that we have today whether it's lithium disilicate or monolithic zirconia where we can do cutbacks you know we're in a great spot because we've got some very durable types of materials that we can make Restorations out of but it doesn't mean that they're infallible and actually our ability to control force in through the occlusion now is more important than ever because our restorative materials won't really break and then the other thing you have to think about is when we talk about reconstructing somebody not only aesthetically but functionally then we have to figure out well where are we putting our functional two surfaces three-dimensionally to make sure that the insis of edges are vertically and horizontally in the correct position whether it's the maxillary teeth or the mandibular teeth what are we doing with our anterior guidance what are we doing how are we managing our envelop of function and these become very critical decisions that are tied into how we're managing our vertical Dimension as well and the problem was is that in dental school we were really just trained to identify a problem whether it's a broken tooth and then we immediately go into a definitive fix and we don't really contemplate what caused this problem in the first place and then if we put our restorations in something that's unstable then we start to get into the frustrating part of being a dentist is when we don't get predictability and when we don't have predictability then we don't have profitability and then Dentistry just isn't that much fun to do and Dentistry Can Be Fun Dentistry should be fun and the good news about putting yourself in a position where you can solve bigger problems for your patients is that typically means you're going to be in a position to be able to make more money and that's a beautiful combination and you think about you know who makes the most money in the world whether it's Jeff Bezos or Elon Musk these are all people that have solved really big problems and that trickles down to us as well ands then you can start to make more money and there are these people they're out there everywhere so what does it look like when we get vertical Dimension wrong well this is a great example of when vertical Dimension gets opened and we aren't doing it from a repeatable position and we're going to talk about some of these nuances that we need to talk about when it comes to opening up vertical Dimension but most people get their vertical Dimension opened in their maximum intercuspation and for a vast majority of people well over 90% your Centric relation and your maximum interc SP are not the same thing and when you have a discrepancy functionally in your occlusion because of a difference in C to joint position versus a habitual bite then typically there is an adaptation that's going to occur and when there's two structure interfering with the adaptation that needs to occur we start to see failures in the Dentistry now let me look at another let me show you another case and and unfortunately I'm in the UN inable position in my local market to where I'm usually having to do a lot of second opinions when cases are going wrong and so this patient came in really frustrated and she was in the middle of treatment so you can see there's permanent Restorations that have been placed on the lower and then there's a there is a full large masary Restorations on the mandibular I'm sorry on the maxillary and the patient was coming in complaining of a lost bite sensation which means that she felt like she couldn't bite the same way twice she was also having discomfort in her temporal mandibular joints and she was also having increasing frequency of being stuck shut to where she felt like she couldn't open and so what I'm going to put up on the screen here now is this is a cbct of her left and her right side joint and if you look on your screen I hope you realize that there's really big difference in the health of her joint on the right side versus the left side there is a lot of adaptation at the level of bone that is occurred for this patient and I hopefully all you can see that on your left side of your screen is actually the right P the patient's right side joint and so if you look where my cursor is on the screen this is the inner or the medial pole of the cond and what you can see is that there's no space in there and you can see how much adaptation and remodeling remodeling has occurred in the glenoid fossa on the medial aspect and look at the amount of volume or vertical change that has occurred on this cular head on the right side joint versus the left side joint and so this is just a great example of what Dr doson used to say is that if the joints are not stable and healthy anything that you do to the dentition is not going to be stable and healthy and unfortunately this is exactly what was happening for this patient is that they couldn't quite get into a good repeatable solid bite for the patient because the joints were constantly changing so it's like a dog chasing its tail it's the worst possible position to be in as a restorative dentist if you're starting to do some large restorative cases so let me show you also on the cbct you can see that there's a periapical abscess pain but I want you to also notice look at how how tall the clinical crowns are on this patient as well you can see that the vertical dimension of occlusion has been opened up significantly on this patient now you can also see that there's radio um there are periapical radiolucencies up on the ma maxillary teeth as well and also on one of these brand new Restorations down here you're already seeing that a clinical Crown is fractured within the restoration so everything is kind of going sideways on this patient and a lot of it is started with the problem that opening up the vertical Dimension was happening in the patient's maximum intercuspation at the same time as that there were unstable joints for this patient when the case was started and I'm these are really tough spots because you know my job as a clinician is to is to help the dentist and not to try to throw anybody under under the bus by any stretch of the imagination but you are diagnosing you know most of the problems that Dentists get themselves into starts with a failure to diagnose and let's think about things on the left side of your screen which is the general dentistry side because all of us have encountered situations to where we miss something and the patient now is having a problem and when patients have problems they start to have trouble adapting you can even do it on a single unit restoration to where if somebody has an unstable relationship and now you just change that one tooth you change the shape the size you change the cuspal inclines and all of a sudden now the patient has trouble adapting and when the patient has trouble adapting who do they blame they blame us they blame the dentist and now the dentist owns the problem and if you don't have the clinical skills to diagnose fully the entire static napic system what do we get ourselves into we get into into awful stressful situations because Dentistry is not fun and when when we become stressed that typically leads us into a fear type of response now let's think about things on the right side of your screen which are when you start doing large cases and you know anytime you start getting into four six units full arches 20 units full mouth rehabilitations a lot of times the problems with the system whether it's the joints the muscles the back teeth the front teeth how these four components are working together and especially on people that don't have a stable bite relationship and they have a discrepancy between their habitual bite or maximum intercuspation and Centric relation the same thing starts to happen just like what I was showing you on this patient before is that they start to have trouble adapting the patients have TR adapting the problem that leads to stress so when dentists become fear F what they start to do is they basically just build this little fence around themselves one teeth or two teeth and then I don't like to get outside of that comfort zone because bad things can start to happen I get frustrated and the next thing you know we're trapped into doing Dentistry that's best for an insurance company instead of doing Dentistry that's best for our patients and so the solution to all of this is to be able to go through a process of determination figuring out where do the teeth need to go in space to be in a functionally and aesthetically correct situation what is a process that we can go through that you know when you think back to your dental school experience a lot of times what happened is in as as we're going through dental schools if we have a patient that needs one one or more teeth worked on maybe it's three or four teeth a lot of times those patients kind of get ripped out from under us they get set to The Prost department and then we're told you're just going to be a general dentist you're going to be good at working on one or two teeth and they tell us treatment planning is very difficult we're going to leave that for the pradon well it's not that difficult treatment planning is not difficult you just need to be able to take all of the complicated problems you see break them down into their individual components and learn to solve those problems one at a time in a proper sequence and that's exactly what Dr Dawson was describing all these years determination of precisely correct size Ledges is the second most important decision a dentist must make regarding occlusion Centric relation being the first you think about how many times have you had a patient that broke or chipped in size of Ledges how many of your patients have broken shes already in their mouth typically and sial edges are the Canary in the coal mine so to speak when accusal problems are not going very well then one of the most important things for us to do is to learn to verify what it is that we're doing in our provisional Restorations our provisional Restorations are not temporary Restorations they are the opportunity that we have to control quality and the way that we control quality is through verification verification of Aesthetics verification of function and verification of phonetics and your provisionals offer you the opportunity to verify those three components and if you need to make a change I would rather have something break in the plastic phase because I can repair that in the mouth instead of having something break once we get the permanent Restorations place for the patients because then when we start having to replace or repair permanent Restorations that means that we're losing money and when we're losing money we become frustrated and when things are breaking it's not predictable and then Dentistry just simply isn't fun so determination verification and then putting ourselves in a position of communicating with a laboratory because your primary way to communicate to your laboratory especially if you are changing your vertical dimension of occlusion is to allow your Temporaries to be the blueprint for your laboratory to follow you see it's not our job it's not our job to figure out I'm sorry it's not the laboratory's job to figure out where the teeth are supposed to go in space the shape of them the size the golden proportion the width the length ratios that's our job as a restorative dentist their job is just to give us a prettier version of what we did in plastic and return that to us but our Prime Ary way of communicating with the laboratory needs to be the utilization of our provisionals it's easier now than ever because now we can just digitally scan our provisionals and they can bioc copy them so communicating with the laboratory is now easier than it's ever been in dentistry you can still do it the oldfashioned way by making stance off of your provisionals creating a custom andal guide table that's still possible but now it's easier than ever all right right so let's talk really briefly about some of the myths about vertical Dimension and I'll just remind everybody please if you're if you have questions I saw some people raise their hands make sure you put it in the Q&A box if you have some questions that you want me to go over and if you're on social media with us right now go ahead and put in the chat boxes and Dylan in the background will be managing those for us as well so what are some of the myths about vertical Dimension well one of the biggest ones is that Comfort we have to figure out a comfortable vertical dimension for your patient and here's what I'm going to tell you you can open up vertical Dimension five millimeters on a patient and if you do it correctly they won't really have a sense that you have changed their vertical Dimension so we're not trying to find a comfortable vertical dimension for patients and we'll we'll go into more detail on what this looks like in a minute speech and freeway space is not how you determine it with natural teeth now it may be a way that you do it with a removable when you're talking about Dentures but not with the natural dentition the rest position is not how you find it and here's one of the other things people rarely lose their vertical Dimension even in Rapid and um uh Extreme Wear cases rarely do people lose their vertical Dimension the times when people lose their vertical Dimension is typically when you have splayed teeth because of per Donal problems or somebody that may have gotten themselves into a position to where they suffered some sort of a trauma as well but loss vertical Dimension is very rare and I'll I'll talk about that in more detail here in just a minute and the last thing I want to tell you when we start talking about the myth about vertical Dimension is that this is not a testing device I see so many dentists who talk about that they'll make a piece of plastic to go in between somebody's teeth to try a test out of appreciable evidence of whether or not you should open it or how much typically when a dentist sticks a piece of plastic between somebody's teeth they're they're diagnosing them with an acute acrylic deficiency what that means is I don't know what to do so let me put a piece of plastic in there and hopefully that'll seem like I'm doing something all right so what should we be concerned about when we have a patient that needs to have their vertical Dimension opened well number one is why are we in a position of needing to open up vertical Dimension well probably the most common problem has to do with a clal disease so clal disease is the most common dental disorder and also it's the most undiagnosed Dental disorder but accusal disease causes most of our patients all of their problems that get them into a situation where they need to have extensive Dentistry one of the things that we weren't taught in dental school is that exposed Denon is not normal and healthy it's not supposed to be exposed to oral cavity you think about it how much two structure needs to be lost for Denton to be exposed and in most instances it is a tremendous volume of enamel you need to think about denting has an open wound and like any other part of your body if you have an open wound it needs to be treated it needs to be addressed because it's only going to get worse I have never seen a tooth heal itself and as you come through the Dawson Academy one of the biggest Paradigm changes that you make is that Dentin is an open wound and if it's exposed it needs to be treated and I know what you're thinking right now you're probably thinking oh my gosh I've got literally more than 50% of my patient base has wear into Dentin well it's not going to get better it's only going to get worse and for the vast majority of these patients they're usually not complaining about being in pain and it's your job as a physician of the masory system to diagnose it to educate it and then at least give patients the option to treat it don't force them because of your inability to diagnose no or because you don't know how to treat it don't force them in a position to where 20 years from now their treatment options are going to become very limited you know every single patient that reaches a terminal dentition becomes the train wreck in their 50s or 60s or 70s started off as somebody that was 25 or 30 years old starting to show the early signs and symptoms second question that we need to be concerned about with regard to opening up vertical Dimension is what is the health of the temporal mandibular joint remember what I was telling you if the joints are not stable and healthy anything we do to the dentici is not going to be stable and healthy and there are so many of your patients out there that the reason why you're having to do extensive Dentistry on them and they have wear into Den in of the posterior teeth or you need room to restore and you have to open up vertical Dimension there are a lot of these patients that the reason is they have breakdown or history of breakdown at the level of the joint and a lot of times these people can be hiding in plain sight a lot of times these people have adapted to the amount of discomfort that they have that they don't think that there's anything wrong with them because they've been uncomfortable for 20 years and they don't know any better they've learned how to change their habits or their life to be able to accommodate the loss of function or the decrease of the quality of their life and they're hiding in plain sight so we always have to learn to be able to die the condition of the joint and then be able to treat the joint if it's not stable and healthy before you even think about opening up a patient's vertical Dimension what else should we be concerned about well we need to be worried about what changes are occurring related to functional Aesthetics you know most of our patients that were thinking about opening up vertical Dimension were having to restore their anterior teeth as well and give them a smile makeover remember most of these patients are coming in the door because they want prettier looking teeth and they don't know what their problem is they just know that they want better looking teeth and so there's a lot of different determinant of Aesthetics that have to be considered in conjunction with opening up vertical Dimension so what kind of cases are common that we're going to run into that we need to open up vertical Dimension well one of them we kind of already talked about which is somebody that has the extreme D extremely worn ition and the thing that other thing that we have to be worried about with these patients and we have zero time to even get into that is don't forget about Airway because bruxism acid problems oftentimes go hand inand with people that are having an airway issue as well so always be aware of that as well when you have these patients with the extremely worn dentition another type of patient that we run into the type of patients that we need to keep our anterior disclusion shallow because if we add in size or length we will make them deep and steep we call that cow trapping that's why I call it because you think about you look at a patient on your screen like you see right here you see a lot of wear into Denon you see flattened maxillary and mandibular anterior teeth these are people that like to go out horizontally well if you get these people into a deep steep anterior overjet overbite relationship what do you doing you're trapping them people that like to go horizontally we need to make it as easy as possible to get them off of their back teeth another big one people that have extreme Ling will wear so what you see on your screen is a great example of a patient with a previous history of Bia when you see loss of two structure from The Ginger Bible margin all the way down to the insis of ledge this is very significant for somebody that's having a problem with acid in their mouth and a lot of times what do we need on these people we need room to restore and so the first thing that we're thinking is opening up vertical Dimension another big one patience that we have to correct accusal plane problems accusal plane problems cause us all kinds of problems when we think about getting in and getting predictable Restorations placed in people's mouths this brings us back to our you know most of most of you'll have little Shivers when I say this curve of SP and curve of Wilson curve of speed being what happens to our accusal planes from the anterior to the posterior and the curve of Wilson being what happens laterally in our transverse relationship so when we think about correcting accusal plane problems a lot of times what we need is room to correct those and that's why these are commonly cases where we have to open up the vertical Dimension and the last one that we'll talk about are people that have deep bites that need Dentistry so you look and you see this is a patient that had orthodontic treatment three different times in her lifetime one time as an adolescent two times as an adult and this is a common scenario people that keep giving their teeth moved but the orthodontists are ignoring the instability that exists on the teeth already and so now you have a patient that's being left in a very deep overjet overbite relationship and now they need room to restore and what do we end up having do in these patients is open up their vertical Dimension all right well let's try to make this a little bit more easy for you to understand because vertical Dimension as you're going to find out has everything to do with what we're doing with muscle so what I want you to understand is that as your teeth are erupting they keep erupting until they meet an opposing force and that stops the eruption of the teeth your vertical dimension of occlusion is set in your max maximum intercuspation to the repeated contractural length of your muscles of mastication more specifically your masser and your medial teroid we call those kind of the sling muscles because if you think about it your mandible remember it's just one piece of bone that starts in the anterior and ends at your Condes and it's hanging there in a muscular sling which is comprised of your Mader and your medial terago now what happens is that you're when you start to lose tooth structure or your teeth are erupting they're going to keep erupting until they meet an opposing force and when a lot of times when people start to lose tooth structure as an adult what happens is that the entire Dental Alvar process is elongating to compensate so many times like what a frustrating situation if you look at the diagram on the right side of your screen is you have patients that come in that they've had all kinds of loss of of volume of two structure on the facials of the lower anteriors and the linguals of the maxillary anteriors they start to get super eruption they start to get a constricted envelope of function and these teeth keep super erupting until they start to hit the gingiva lingual to the maxillary anterior teeth and a lot lot of times these patients come in they've snapped a tooth off at the gum line and they want a partial denture now and now you don't even have any room to give them a partial so we all see this every single day clinically in our practices and so what happens is as these teeth keep erupting until something stops them if you have to structure that's in the way of that repetitive contractural length of those muscles of mastication Dr Dawson used to always say this when teeth and muscles when they go to war teeth always lose the war no matter what because muscles can keep going on and on and so when when researchers are studying vertical Dimension they aren't measuring it at the level of the teeth or the CJ what they're what they want to look and measure if they want to see changes in vertical Dimension over time is bony landmarks and as as the researchers have studied this what they have found is that even with rapid abrasive wear most people do not actually lose their vertical Dimension there is simply the compensation that happens through the eruptive process of the teeth and the elongation and an adaptation at the Alvar process so if we open here's the here's the thing that's a little bit scary it doesn't mean that we have to be fearful of opening up vertical Dimension it means that we have to learn to open up vertical dimension the correct way if you open up vertical dimension on a patient for the reason of restorative room then the patient will typically revert back to their original vertical Dimension within a six-month period of time and it can actually stretch all the way up to 12 to 18 months as well now here's the deal if you do it with proper principles which means a seated joint position InCentric relation on healthy joint or unhealthy joints that have readapted to being healthy and you can verify you can meet the five requirements of a clal stability then these patients won't know that that adaptation is happening going back to their original vertical Dimension because when you stretch and elongate these muscles of mastication original vertical dimension so there's a couple different studies that highlighted this one of these was from rickets and what did they show is they showed that lower facial Heights in adults stayed constant with age and what they showed on over a thousand orthodontic patients is that changes in vertical Dimension rted back to the original vertical Dimension within one year another study that recently came out in 2011 was talking about that the strains if the strain is beyond the Adaptive capacity then you'll start to see negative changes from that but if the changes and the increases of the vertical and the increas vertical we're done and the occlusion is stable then they will go back to their original vertical dimension of occlusion without them knowing it and this is something that was expounded on 1984 in the Journal of prosthetic Dentistry now here's the million-- dooll question how does vertical how does the cular position affect vertical Dimension so I want you to look here these animations and remember what I was saying before is that think about your mandible now is just kind of hanging in a muscular sling your M your medial teroid and that mandible now can pivot anterior to posterior within that muscular sling and so if you look at this diagram here somebody is in their maximum intercuspation and it's not the same as vertical Dimension and when this happens the compensation occurs with a cond coming out of the glenoid and being stabilized down the articular so that all of your teeth touch in your maximum intercuspation now an amazing thing happens when you put people into Centric relation when that Mand PIV pivots up into a fully seated position of centric relation which means you have a bone disc bone relationship the cond has achieved its most vertical position it vertically can't go any higher and in this position the mandible now can have a point of pure rotation now remember your condal does two around a fixed point and then once you open about 20 mm or more then you go into translation and your condal comes down the articular Eminence as you open and then returns back to its fully cated position so the temporal mandibular joint is actually the most complicated joint in the human body which is kind of scary because that's our domain and we weren't really trained in dental school on how to treat it now the amazing thing about this is that when that mandible P pivots up into Centric relation the vertical dimension of occlusion is not increased because those muscles are not being stretch the muscle length is exactly the same and in about 10 which is de-stressing the system it's amazing because what do you need most of the time what you need in people with a really worn dentition is you need room to restore the anterior teeth and I know this is kind of complicated to talk about in a in a minute webinar here but I always consider Centric relation to be the eighth wonder of the world because it is typically the solution to most every restorative problem that we have when it comes to a complicated case so there are situations to where you can drop the PIN to the table maintain that vertical Dimension at that first point of interference and Centric relation and then you are additively equilibrating or adding back to structure that's been missing and you haven't increased the vertical dimension mention now you may say well Lenny the teeth are separated in the front and I'm going to tell you yes they are they are separated in the front but what happens is that vertical Dimension we're measuring that at what relates to the level of the muscle at the joint and the muscle is not being increased in L and by getting into a full fully seated vertical position of centric relation actually can't go any farther and now it's a pure rotation there from that first point of interference and Centric relation to that pin being back down to the table we haven't changed vertical Dimension and I'll tell you what the first time I heard that when I heard Dr Dawson speak the first time that was a mic drop moment for me I could not believe what I was seeing before my eyes because nobody taught me that before so the reality is most of the time when you have patients and you have the ability to diagnose the system the stomatic NAIC system the joints the muscles the back teeth the front teeth when you have the ability to diagnose that when you have the clinical skills to record Centric relation and you have learned how to two-dimensionally and three-dimensionally treatment plan what you're going to find out is very rarely do you actually need to open up somebody's vertical Dimension and the times that you do r ly will you have to do it more than 3 millimeters at the level of the pin that would actually be for most cases a very large opening up vertical Dimension if you can do it from Centric relation if you know how to do that and it's not difficult you just need to in invest the time and the money to be able to do that now remember I'm trying to give you a lot of tips and tricks here what are the cases you got to be really careful of opening up vertical Dimension while any case involving implants remember that implants are not like Teeth they don't have a PDL implants cannot adapt to mismanaged force they will either fail or they will break one of the two denture patients and anytime you're doing a removable partial denture as well be careful opening up vertical dimension on these patients all right now let me show you a case really quickly of how we manage vertical Dimension and how we utilize our provisionals to control our quality in these types of cases so this is a patient M named Alona she came in wanting a smile to makeover she just wanted to work on her party teeth she was ready to spend the money to work on her sixer or anterior eight teeth but when you pull the cheeks back this is what you have an accusal plane Nightmare and one of the things I'll tell you is if you're going to restore these types of patients the five requirements of accusal stability have to be met I wish we had time to go into the details of those but you know if we want to train you how to do this the right way we're going to have to have you come through our Core Curriculum all of our seven courses that's how we train you these are complicated things to deal with all right so you can see the irregularity of the arch forms and so what we do is we start to go through our treatment planning process two-dimensionally one of the first things that we're looking at is lower and szal Edge position this should either be straight or actually ideally slight convex but never concave and what do you see here you see a really large concave lower anterior clal plane remember that your lower teeth are the hammer your upper teeth are the nail and if you aren't controlling how the hammer is hitting the nail good luck having your Restorations on your maxillary anterior teeth last I see too many people that comeing to see me for second opinions because they just had maxillary anterior teeth restored that aren't working out well because they're chipping or they're breaking or they're having phonetic issues and I see lower anterior teeth that look like this you can't do it the right way when you ignore the lower front teeth then we start talking about finding a correct incisal Edge position on the maxillary teeth we look at our rest position we look at our e position we analyze the horizontal positions as well because this relates to our envelope of function and also to our phonetics Buckle Corridor golden proportion figuring out the proper width the length ratios now here's the deal anytime I have a patient that I'm getting ready to do multiple units of restor restorations I always start with three-dimensional Imaging making sure that the joints are healthy it also gives us a snapshot at a point in time of the airway and what are we typically finding a lot of people that have hidden Airway issues this patient their total Airway volume was 9..9 CC's the average is about 20 to 21 so then the patient's getting a sleep study done supporting their breathing a lot of times what do we find when we're doing three-dimensional Imaging is other problems problems with sinus issues this patient had a fungus ball in her sinus so she came to me looking for some help with our maxian tior Aesthetics and about nine months later we actually finally got to it because we had to treat all these other problems that we're seeing first until we can get in there start to do our wax up start to figure out how do we bring these puzzle pieces together opening up the patient vertical Dimension to be able to solve the accusal plane problems to eventually test drive the results in plastic so these are the provisional Restorations that you see on on your screen right now the before and the after and those are provisionals on a case like this I'm going to leave these patients in their provisionals probably for two to three months at a minimum because I want to make sure did I Cross My te's and Dot my eyes did I solve the functional problem did I solve the phonetic issues and did I meet the patient's aesthetic desires and then these then become a blueprint for my laboratory to follow always doing my photographs lines in the front dots in the back you'll hear us say this all the time at the Dawson Academy and then my laboratory is just trying to go through copy what I gave them in plastic and give me that now in a permanent restoration and when we can do this the right way we get unbelievable aesthetic results the patient becomes happy we can count on the fact that our Dentistry is going to last because we have solved the aesthetic problem that is caused by a functional problem proper form or Aesthetics follows function not the other way around and if we're going to be able to do these types of cases predictably and profitably in our practices what we need to be able to do is manage a patient's vertical dimension of occlusion and make sure that when we do this that the joints are affecting this the airway is affecting this and our ability to properly treatment plan is the key to our successful outcomes in these patients ultimately if you want to start to do these types of cases I want everybody just to realize you already have all the patients you need in your practice right now to be busy for the next 10 years they're just waiting for somebody to be concerned about it most of your patients are suffering but what we're doing in our practices is we're always treatment planning what's best for their insurance coverage instead of what's best for the patient and this is a Paradigm Shift within your practice and what we call that in the Dawson Academy is learning to become a complete Care dentist once you start expressing Compassion or concern you're going to have to start to express compassion because you're going to have to give time for your patients to own their problems time to start to figure out how they can pay for it because people inherently always want to do what's best for themselves and ultimately you're going to get the opportunity to provide care for these patients as well if you like what you're hearing and if you like what you're seeing what I would invite you to do is come and join me for two days in Charlotte in January our first course of our seven course cor curriculum is called functional occlusion and we will open your eyes to all the things that you never thought about show you the reasons why your Dentistry is failing why you're frustrated why your patients are frustrated give you confidence in learning to diagnosed the static neic system show you the treatment planning that we do two-dimensionally and three-dimensionally and all of the aesthetic and functional things that you should be thinking about as you learn the treatment plan correctly so if you'd like more info please snapshot or or grab that QR code it'll take you to our website and with that I thank you very much