Hello, my name is Dr. David Flamenco and today we're going to be going over how we can get a proper bite acquisition for an oral appliance. So I'll show you everything that we're going to be using today. We have our metal retractors here in case you need them. I just usually use my finger when I'm retracting and using the scanner head. We have our size 15 blade that'll be for removing any excess on the George gauge later on with the bite registration. Then we have our blade holder. We have our Explorer with periodontal probe, our intraoral mirror, cotton pliers, bite registration. In this case it's a fast set so just make sure everything's perfect before you even use this material because it is pretty fast. You have about 20 second, 30 second working time depending on how hot it is in the room. So you might want to even use regular set if you're starting off with this just so you can correct the bite if needed. Otherwise there's no forgiveness using this material. Then we have our autoclavable George gauge body right here. We have our fork. It's a three millimeter bite fork. This is not autoclavable. We have two different types of scanner heads. One is a regular size, the other one is a smaller size or slim line in this case. So we can actually get those distal areas on the molars. And then I have a cup of alcohol here just so I can use these two cotton applicators. One of them is actually going to be to moisten the cotton applicator and remove any type of residue that you might see on the glass of the intraoral scanner head. So sometimes you will have some water marks on there from the sterilization unit. So you want to make sure you put a little bit of alcohol, wipe that off, use a dry one and you can wipe off any residue that's left there to make it nice and clean so you don't have any discrepancies. And I usually keep gauze here just in case if you don't have a airline. So we have our air tip or air water tip on a syringe so that we can actually place some air on there, get rid of any saliva bubbles so the laser can actually capture the teeth properly and there's no discrepancies there. I will put a little bit of alcohol on here just because I do see a tiny bit of water marks, not much, but still enough to where I can have some errors there. Making sure this is nice and clean. The other one looks pretty good, I'm going to leave that alone. And we're going to start off with a regular body in this instance to capture the upper arch. So if you have a heating element, make sure that you're giving it enough time to heat up the glass so it prevents fogging, otherwise you will have discrepancies. Usually the scanner won't be able to read the surface of the teeth, so that's important to make sure you do that. So I'm just going to get this started here. Alright, so this does have a positioning sensor on it. So we are going to make sure that we're starting on the right hand side for this just because that's how the algorithm is kind of orientating the data while we're scanning so it'll know how to actually position the arch. You can change that in most of the software and tell it exactly where you want to center the object. And you're going to open please. So we're going to start on the most distal aspect of the occlusal surface. So we're going to follow this scan pattern here. So I'm going on the occlusal surface here and just following around. So I can see I'm having issues capturing that distal aspect of the teeth. So I'm going to just kind of rotate here and I'm just going to make sure that everything is okay. So I do see on the distal aspects I'm having issues that it's not capturing 100% there, but on the interproximal areas it looks really good. I can see that little tiny dot that's on that molar on the top left hand side. That's not a problem. Usually the software will fill that up, but anything that's over 2mm, 3mm, definitely I try to pay attention to that and see what kind of algorithm they use to fill in those voids. So I'm capturing from the opposite side. Same idea. It's the same thing you would do for the upper, if you're able to. Okay, that looks good. Alright, so now we're going to capture your bite. For that, you can use a slim tip or a smaller scanner head. In this case, I'm going to use the regular one just because it's easier to capture enough data there so it matches properly. Most of the softwares do recommend that you just capture a small portion and then it stitches everything together. I recommend that you actually try to go across the arch if possible, so that way there's no discrepancies or creating a virtual cant, for lack of a better term. So I'm going to go to a buckle bite. And for this, this is going to be the MIP position. So for the open bite, we're going to actually have to use the George gauge for this and take the bite for that open bite. So you're going to open please, and we're going to capture MIP. So for this, I'm going to have you bite down all the way. You're going to kind of feel this right there, and I'm just checking midlines, making sure they match. Okay, you're going to open again, bite down again, and I can see the midlines off to the left just slightly on both upper and lower. Open again, bite down again, okay, and you're going to open again. Alright, perfect. So you're going to bite down again. I'm just making sure that that matches. Perfect. You're going to hold that bite for me. And like I mentioned, I am going to scan on the upper first. I always stick to one arch first, make sure that it matches properly. Great. Just getting enough data here, and then I'm going to go over to the other side. You're going to hold that. Yep. You're going to bite down again. Yep, that's okay. You're going to hold that bite, relax your cheek, open again. Okay, bite down all the way. Hold that bite. Try not to open. And now I'm going to scan the lower, and it's going to match the upper to the lower. So try not to open. If you do open or have to swallow anything, let me know, just because that can cause a discrepancy with this. A reason why we have the keratinized tissue in there is, as you can saw how that matched really nice, is because I was actually grabbing and capturing enough data of the keratinized tissue, which allows the software to match everything properly. Because sometimes it can't match just the teeth. Because if you see this overbite that's existing right here, it won't be able to match the teeth properly because there's not enough data for that scan. But if you have enough keratinized tissue, it can match the keratinized tissue to keratinized tissue, and then you won't have that issue in that sense. So now that we have our MIP bite, it's already grouping everything together within the software. So the next thing I'm going to do is go with the George Gauge, and we're going to take a look at that. So for the George Gauge, this is a little bit different. I'm going to actually just make sure that the upper incisor notch is perfectly set to the teeth and there aren't any rotations. So I'm going to look at her bite again, and you're going to bite down. In this case, we're going to look at her bite. I don't see any rotations on the upper or the lower to where I would have to modify the incisor notch of the upper or the lower on the George Gauge. So I am going to check the upper first, and you're going to open, please. You can do it the other way around as well. So you're going to bite down. Good. I'm just making sure that I didn't see any shifting. If you do see shifting, it's okay as long as you can have it repeatable. That's fine. And then the next thing I do is just make sure also that there's no shifting when I'm looking at the midline. You're going to open again. Good. Bite down again. Perfect. And I'm just making sure that that doesn't happen. You're going to open again. So I'm going to look at the lower aspect as well. So for this, we have a screw turn aspect to this that allow us to actually move the incisor notch, or incisal notch in this case, to tighten it. So you're going to open, please. So I'm going to use my finger here. There's a little bit of rotation here on the lower, not much, but I'm going to use my finger here to hold this aspect of the lower incisor notch. And I'm using that little plastic that's right there, holding it there and against the lingual side of the teeth, sliding it towards the lingual side of the teeth, and then moving this George gauge towards the buckle aspect and tightening at the same time, but making sure that I'm not over tightening anything so that it can be repeatable. So I'm making sure this is nice and tight. Good. And I can see here is no flexing within that little frame here. So that's why I had my finger on there. So I made sure there's no movement to it. So that fits really nice. And now I'm actually going to check here by bringing the patient back slightly because I do want to overlook the patient. So for this aspect, we do want to take a look at one thing, which I'll go over shortly. So we're going to make sure that we do have, you can open please, making sure that we do have a fluid movement. So when I'm placing this bite fork that's on here, I'm making sure that there's some free movement to it. And that is not too tight so that the patient can move her jaw forward and back. So I can see that there's enough movement there. It's a little bit slightly restricted, but not too bad. So it'll still be enough for her to be able to move her jaw, to protrude it and to retrude it. And you can open please. So I'm going to just check here and you're going to bite down. Good. Perfect. So you're going to grab your jaw, slide forward and back. Okay, good. You're going to open please. So now we're going to actually take a look at this at a closer look. All right. So now we're going to make sure that we can check MIP. So I'm going to follow the lower incisor notch one more time, making sure it's in the middle, making sure the upper incisor notch matches. You're going to bite down again because I did see there was that relationship was a little bit off, but in this case we're centering it midline to the face. Good. Perfect. Does that feel comfortable where you are? Okay. You're going to open please. Good. And I'm just checking this here. So we do have it as a negative six as our MIP and you're going to open again. So that's a comfortable position. That is a comfortable position for her. Okay. Now you're going to bring your jaw as back as you can or as protruded as you can. Now bring it as forward as you can or most protruded as you can. So bringing it forward is always a positive number in most cases and then also bringing it back is usually a negative number. And you're going to open again. So we have our protrusive range of motion, which was positive three and our retrusive range of motion, which was a negative seven and 50% of those total units, which is 10 units of the maximum range of motion. We do have, we will divide that by two or have 50% of that, which is five. So that would be five units from the most retruded position. In this case, it's a negative seven. So we'll make sure that it's at a negative two. If we need to increase that later on, we can, so we can do the calibration little by little. So I am going to put that at a negative two. So we'll lock it in there and then we'll actually take our bite in that position. So making sure everything's nice and tight, even on the lower, just in case, all right. And then we'll check that one more time from a distance so that way you can see what it looks like in the midline. And then you're going to bite down all the way and then we'll check that. All right. So now that we have this at negative two, I positioned the patient to where I can actually see directly over here and make sure that the midlines are precise. So I'm going to take a look at that lower incisal notch and you're going to open please. Good. All right. And I'm going to have you bite down and I'm going to make sure that it's repeatable. So I'm checking the midlines again and you're going to open again, bite down again. Good. Perfect. And I am going to bring this chair up. Remember, ergonomics is very important as well. So even though I can look up, I do want to make sure that my forearms are technically pretty parallel to the floor if possible, or as close as possible, being able to also see the midline and the incisor notches and you're going to bite down again. Good. Open again. Bite down again. And this is what we're going to be doing. Bite down again. Awesome. You're going to open one more time. And you're going to be accustomed to biting into that position. Did that feel pretty comfortable to where you're able to repeat that? Yeah? Okay. So once that's confirmed, now you can actually go with the bite registration. Because I mentioned that this is fast set, you really want to make sure that you're working at a very quick pace for this. So I did bleed this ahead of time. So I'm going to be using a tea mixer tip as well. This does help to actually save some material if you have these around. They're great, but you know, you can use any type of the original tip that it came with. So I am going to make sure everything is correct here. And what I usually do, if you want to take a look over here, I'll make sure that I'm actually putting the material right on the edges of the fork. The top and the bottom, very lightly, without getting the sides. Because as soon as she bites down, usually those will meet. And because this is perforated, it will actually capture the material from both sides. But you want to be very fast. I don't go over the incisal notches, because then that'll be hard for removing it later on, especially on the one that's autoclavable. And it's just easier to remove for access for the buckle scan. So another reason why I'm choosing this three millimeter bite fork is that I did see that the curve speed wasn't that high. And if I would have used a thinner one, I would have seen some flexing. And then I can have distortion. So when I'm taking that bite registration, also, I was checking with the fork that there was no flexing of the fork itself when she was biting down. If there was, then I would choose either a thicker bite fork, making sure there's enough interoclusal distance to capture for my material and my material selection for the oral appliance. That is very important. Ask your manufacturer or the laboratory what the minimal thickness is on the upper and lower. Sometimes you do have to increase the vertical dimension. And you would want to do it now, not actually in the laboratory, because it's an arbitrary vertical dimension increase that they do from the posterior and anterior at the same time in that vertical aspect. In this case, remember that the jaw is actually moving down in a hinge position, hinge style. So you're actually having more opening on the anterior than you are on the posterior. So to compensate, you want to make sure that you're checking that ahead of time while you're with the patient. You can add sometimes some composite buttons on the back or on the anterior portion to create enough interoclusal distance. So also confirm that before you start with this bite registration material to capture that open bite. So I am going to start now. So like I said, this is going to be quick. I do put some on the back of my hand to check the drying time. So let me know when you're ready as well. If you have to swallow, I definitely swallow now. Because you don't want the patient swallowing while you're doing this. So I already started. I'm going on the top, going on the bottom. And also check to make sure that you have enough material that can actually touch the interoclusal distance. So you're going to open please. Good. I'm going to place this here. You're going to bite down slowly until you feel that notch. Perfect. And I have it right down in the middle, making sure that there's no adjustments that I need. Good. Everything looks great. Making sure everything's fine. All right. So I have it exactly in the middle. So I'm making sure everything's matching here. Good. All right. And we're just going to let that settle. Okay. So like I said, this is facet. So this already did dry on me. So we can see here, this is already ready. So one or two things that you can do, you can scan while she's biting like this. In most instances, you do want to remove. On the bite fork, you'll see a little notch that you can actually separate it by twisting or cutting. Usually I recommend cutting it. You can use the blade to cut even excess material on the buckle aspects. So I'm going to show you right here. So we're going to want to kind of look on the sides and we'll go on this side on the left hand side. So we can see here that there is enough occlusion and keratinized tissue that our scanner will be able to capture that data and match a bite. Same thing with the right hand side. So you can feel me pull here. So we do have enough data for that as well. We don't have to do any cutbacks. I do see that it was exactly enough to get the cuspal tip. So that's where I was saying that you can add more material if required. These were the things that I was checking before I put the material on there to know exactly how much material should be placed for the inter occlusal distance. And I will be removing that bite fork. So you're going to open again. Good. And we can see how we have a clean area here. I remove any type of excess that can interfere with that. And then we can see on the other side, we might do want to clear some material here, which I'll do now. So I'm squeezing down a little bit on the sides, making sure that when I'm going across, I have a clean cut on this material. Okay. And I'm looking at the other side. This side looks pretty good. So I'm going to leave that to the side. I am going to remove this bite fork now. And then I'm going to show you here, if you're able to see this, that there is an incisal notch. So you can see that right there. I'm going to make sure that I'm grabbing here. And all I'm doing is bending it without making sure that this doesn't flex at all. And I just twisted it off after bending it. So I grabbed pretty tightly to make sure that it did not flex and that I was able to remove that. You can use the blade or you can use scissors to do that as well. I'm going to place this back in the mouth. So I'm going to make sure that this matches. I'm going to place my hand here. Good. And you're going to bite down slowly until you feel that touch. There you go. Perfect. All right. Does that feel okay? Okay. All right. So now I'm actually going to start scanning. So I'm going to be scanning my open bite. So for this scanner that has it in different layers, that I can add the open bite to that work group, which is awesome. And we'll continue scanning here. So you're going to feel me kind of pull your cheek again, you're going to hold that bite down. Perfect. So I'm starting to scan now. And as mentioned before, you'll hear it click. Well, in this case, it gives me an audible sound for it. Some scanners are a little bit different, but I'm making sure I capture enough data all the way across. Why? Because I don't want to have that discrepancy. And you can see that the benefit of removing that handle from the fork is so that I can do that easily. So that handle is not in my way when I'm scanning. There you go. I got enough keratinized tissue. I'm getting into proximal areas as well. Now I'm actually going to go to the top and I'm starting again on the right hand side because that is the scan pattern for my scanner. So I'm making sure that I'm capturing enough data from the lower arch to the upper arch. Not jumping so that I can even capture that bite fork to have some kind of reference point and map this out and not put an arbitrary type of match for the upper and lower occlusion. Like I mentioned, I'm capturing as much data as I can. You can see it's taking a little bit of time capturing it because of the amount of data that I captured. That's exactly why I'm doing this, making sure it matches. And I will stop in a little bit to let it catch up. And there we go. It did match. Very nice. Good. So I'm going to stop that there. I'm going to let it organize all of the data and try to match that information. So we're going to take a look over here and just make sure everything's OK. I am going to make sure that we have a nice scan. We already knew that this was off slightly. So that looks pretty good. That's exactly how it matches. I'm making sure that it matches on the top and the bottom. Exactly the same. Good. Yep. Perfect. I don't see any deviation from how it was. The midlines were exactly in the same position on the upper and the lower. All right. That looks really good. OK. So I'm looking at both sides, making sure this is fine. I am going to take away the open byte scan. Yep. That looks really good. That's exactly what I'm seeing here. So I'm making sure there's enough inter-occlusal distance on both sides for the device, which there is. We can also check that with a laboratory. And then there's software in this program that we can actually analyze and check that. But just based off of experience, this looks really nice. So we're going to zoom in a little bit over here so we can take a look and see that the midlines match. So it's exactly the same as what we're seeing on the screen. So that's very important. So we're going to zoom into the teeth and then just take a look. All right. And you're going to tilt your head down a little bit. Perfect. It's very important to familiarize yourself with the software that you have at hand, the scanning patterns, and also what you feel comfortable using, whether it's using air or actually using a gauze to dry off the saliva. Make sure you have a dry field when you're scanning. Make sure they brush your teeth and there's no food particles because there are some scanners that might have issues with that. You're not able to delete the areas and add on to that. So just make sure that that was all corrected. But everything looked really good. So hopefully you guys enjoyed the video and you got to see how I'm able to capture, you know, that bite acquisition using this scanner in particular. Thank you very much.

oral appliance

scanner

bite acquisition

tools

fast-set materials

scanning process