20 Years of Composite Excellence Part 1 – PDP119

Jaz’s Introduction:
Hello Protruserati! I’m Jaz Gulati and welcome back to another episode of Protrusive Dental Podcast. Today we’re joined by Dr. Javier Queiroz, from Costa Rica, who is one of the best dentists I know when it comes to composite resin artistry. This guy has been doing it for so long to such a high caliber. I look at his work and I think, WOW! And I want to basically piece apart his thinking process. How he uses composite? What are the best ways to get the maximum results using composite resin? And what are the sort of limits? When should you consider ceramic? Which is a theme we’ve covered before in the podcast.

But it’s always great to have new perspectives. And what I gathered after recording with Dr. Queiroz is that he’s very pro composite. But he’s also someone who’s placed, thousands of units of ceramic as well. So, he can give us the lowdown on them both. Some of the main themes we cover in this part one episode, because again, it’s one of those amazing episodes, that it’s full of so much value that I had to split it into two and you guys voted for it on the Protrusive Dental Community and on App protrusive dental Instagram page. I gave you a couple of options. I gave you composite additive equilibrations, and I gave you high end cosmetic rehabilitations. So, one was like more occlusion base, one was more actually composite as the material itself, and you guys selected COMPOSITE for this round. So, after the part two, then I’ll release the one about additive equilibration with the composite. So, that’d be a really good one as well.

But for this one, the kind of themes we cover in today’s episode is HOW MUCH CAN YOU LENGTHEN TEETH SAFELY WITH COMPOSITE. Which is kind of an occlusion question as well. But it gives us some guidelines to follow in terms of what substrate, what kind of composite, and planning your occlusal design and smile aesthetics. I asked Dr. Queiroz his experience on how long composite veneers are lasting. He’s been doing it for about 20 years. So, let’s hear it from him with his patient base, how long they tend to last? What kind of issues? And at what point do they happen? And we also cover the theme of what kind of case is best suited to the young dentist.

So, a few years qualified and you’re starting to do more anterior composite work, perhaps you’re doing just basic restorations, or you’re gonna have some composite veneers or edge bonding. What is the ideal case to start with? Because, you want to go with baby steps, right? I mean, I’m a big believer in that, you want to go for the most complex edge to edge bite composite veneers, you want to start off with an easier low expectations, low lip line kind of thing. So, we cover that kind of basis.

[Protrusive Dental Pearl]
The Protrusive Dental Pearl I have for you today is a video that I’m going to play for those watching. But for those listening, you’ll easily catch on trying to say with this pearl. Which is the use of what we called the CASI 3C Instrument . There’s a couple of varieties of this, but I’ve shared this before on this podcast. It’s an instrument distributed in the UK by Enlighten who are the sole distributors of Cosmedent products and if you’re around the world and find your Cosmedent dealer, because they have this particular instrument. Now, what I love about this instrument, I’m playing a video for those watching. But those listening I’m actually building up a lateral incisor freehand. Okay, I’m not doing a wax up. I’m doing like kind of like a mini rehab here. I’ve just done a canine riser. And now I’m building up the upper lateral incisor. And instead of using my finger like I used to use my gloved finger then I used to use like a mylar strip phase. And now I use this CASI instrument because it’s got a perfect spayed-shape with a curve in it that beautifully forms the lingual or palatal contours of your incisors. So, because there’s a nonstick material, I’ve placed it up against the lateral. And I’m literally using it as my stent, my palatal stent for my composite holding in place.

I’m using another one of these same instruments, but the other side of it, which is a very thin, again, beautifully curved instrument. And it’s actually designed for you to also use it with composite veneers. So, this instrument, I like it so much because it’s got that sort of three planes on it that really allows you to adapt the composite in a way that it creates those correct angles and emergence profiles that you need. So, I’m a huge fan of this instrument. So, once again, that’s the CASI instruments. These are designed by one of my buddies, Dr. Carlos Sanchez.

Now interestingly, it’s Dr. Carlos Sanchez, who’s episode and we’re looking forward to next talking about additive equilibration. So, it’s nice how that one we’ve done but he designed this instrument, and I’ve been using it for a few years now since I intended the mini smile makeover course, with Dipesh Parmar because that’s where I learned how to use it and I’m just absolutely loved it. I want the world to know how much I like it. So, that’s my big tip. If you’re looking for a composite instrument, this is my favorite instrument. So, if you look in my box of instruments, I’ve got about three or four of these specific ones. Because another tip that Payman Langroudi gave me is that instead of buying eight different instruments, buy like multiple of the one instrument that you absolutely love using. So, I keep my composite protocols very simple. So, this is the main instrument I use, and it comes in sort of smaller, thinner one as well, which is great for like lower incisor and stuff. So, check out the CASI instrument. I’ll put the links in the show notes protrusive.co.uk so you can get those easily.

Main Episode:
And now let’s get to the main episode, and I’ll catch you in the outro.

[Jaz]
Dr. Javier Queiroz all the way from Costa Rica. Welcome to the Protrusive Dental Podcast. How are you my friend?

[Javier]
Very good! Thank you, Jaz, I’m very honored to be with you with all your listeners.

[Jaz]
I mean, I told you this last time we briefly met we had to reschedule this recording because there was a storm and when I say storm, most countries, you call that a storm? It was, for us it was a big deal. But for the rest of the world, they were laughing at us. But we rescheduled and speaking to you briefly then and it’s just an honor to have people, the caliber of dentists like you listen to the podcast, it just drives me like wow, I can’t believe that. So, thank you so much for your listenership and joining now the community to help and support on a pretty big topic, composite versus ceramic, which I’m really excited to delve deeper in today. But for those people who haven’t seen your wonderful work before, don’t know much about you, please introduce yourself, Dr. Javier Quiros.

[Javier]
Well, I’m Javier. I’m from Costa Rica and I am a restorative dentist. I also prosthodontist and I work here in Costa Rica. I teach and I’m a wet finger dentist, I see maybe from five to ten patients per day. And I do a lot of full mouth rehabs and now that I’ve Aesthetic Dentistry, and today what I would like to share with you guys is my my experience of over 20 years of teaching and private practice about which material to choose whenever it comes to cosmetic dentistry and full mouth rehabilitation. So, thank you Jaz for your kind invitation.

[Jaz]
Guys. We’re in for an absolute treat. I know it. I mean, just behind so those of you listening, don’t worry. I mean, have you listened to the podcast while he’s on the treadmill? So he appreciates that. You’re just listening. If you’re driving to chopping onions, he will make it very descriptive for you. But for those of you who are watching it, oh my goodness, you get to see the beautiful work that Javier does. But Javier has promised that he’s going to make it really descriptive. So, and really tangible. So, even if you’re not watching, it’s okay, you’re gonna get the real deal. So, let’s start with a big question straight off the bat. Let’s start with bigger picture before we niche down. Why is it that in the last for me, I think I really started to notice composites take a huge hit about 2013 when I was qualifying, and I started to see more and more from that point, a composite veneers going quite big? What drove those trends? And what about you as a wet fingered practicing clinician for over 20 years? At what point did you start saying, “Okay, wow, this composite stuff, it works well for veneers!” When did that shift happen for you as well?

[Javier]
You know Jaz, I started like everybody else, I thought my lab technician could solve my problems. And so, I just prep teeth and send that impression to my lab technician and hope that he could solve all the aesthetic problems that my patients have were having and build those smiles like I would imagine them too. But you know what, I was very disappointed when I saw that my lab technicians could not make a smile the way that I wanted to. So, I started looking at a composite veneers. And then I had an epiphany, it was that if I didn’t learn how to make teeth myself, Jaz, not my lab technician but myself, then I will never be able to do a great smile on my patients. And so, I started first doing porcelain, but then my lab technicians would do something else that I didn’t wanted it to. So, I first do them in composite then prep on top of composite and then my lab technician only had to do a very thin porcelain veneer and I would bond that in top of my composite but then I was doing the work twice.

[Javier]
Then I find out the wonderful material that is microfill composite, which is a very thin layer that I put on my veneers at the end, microfill composite. And that looks just like enamel, it looks just like feldspathic porcelain. And so, that was my trip. It’s been 20 years so I started with full porcelain. Then I moved to feldspathic then composite and porcelain and now I do microhybrid composite and microfill composite on top. And you know what, Jaz? Among independent dentist, I don’t rely on my lab technicians for them to build the smiles. I’m the sole responsible of how my patients look at the end of our appointment. And I’m so happy and I’m so free because of that. I have all kinds of experiences with my lab technicians. I was doing maybe one or two cases, of porcelain veneers per week. And suddenly my lab technician just doubles his fee. Or suddenly my lab technician says that he didn’t want to do any more feldspathic because he bought a CAD CAM. And now I had to prep three-quarter crowns because his CAD CAM would not read my preparations because they were too conservative. So-

[Jaz]
Something sounds like it was a born out of frustration, initially.

[Javier]
Yes.

[Jaz]
And then, it evolved into an artistic form for you. And then, it gave you full control. Now, you mentioned a few important things in there. Now a lot of my listeners will know about the difference between microhybrid composites and microfill. But for those who don’t, please, can you just explain the chemistry a little bit behind them. Why microfills have such beautiful possibility, like, from the one that I’m aware of in the market in the UK, is by also by Cosmedent is renamel which is just a beautiful composite. Dipesh Parmar teaches it on his two day course in the UK. And I’ve been there twice now, what a beautiful composite that shine, it has. I’m yet to find another composite to give that but that’s all behind the chemistry of it. So, if you just describe the differences in those two composites, just briefly.

[Javier]
Yes! So here in the screen for those in YouTube, I have microhybrid composite, which is a stronger material because he has bigger particles. So, it blocks unwanted color. It’s got great flow, it’s got the best tensile strength and is the best material for incisal edges and is very strong for posterior teeth. So, this is a slide that, if you guys are not looking at this, you can see in an SEM slide or a photograph, you can see big particles of filling material on your composite. And those big particles makes the microhybrid composite very strong, is very strong. This is compared to maybe what maybe emax or maybe something like that, very strong, but then it’s microfill composite. Microfill composite is a very small filler content material and it polishes through an enamel like it’s very translucent. And it’s got long term wear resistance because the particle is so small that whenever you get one of those fillers to pop out, the eye will not see it. So, they come back to your patients, will come back with their veneers still polished then you don’t have to polish them every time that you see them is very color stable. The only disadvantage is that it has the lowest strength of both of them. Microhybrid is stronger. So, what you have to do is first good microhybrid and then microfill composite on top of it and then you will have great results, Jaz, like the ones that you’ve seen.

[Jaz]
Although the only one that we, just to be complete for the geeks out there, the only one we haven’t mentioned is a nanofilled which is the best of both worlds, right? We can assume that that’s the best of both worlds and because I already want to get into the composite versus ceramic debate with you. It’s just good to know guys that these are three main groups composites and why have you described in microhybrid almost like the core ceramic if you like equivalent and the microfill like a layering ceramic in an equivalent way? Do we adopt that thinking?

[Javier]
To follow up on your question that nano is like a blend of both of them, Jaz, and if you want to have just one material then you can purchase nanofill but if you want the strongest, you first put microhybrid. Microhybrid is even stronger than Nano. If you want the one that polishes the best then you use microfill. Microfill polishes better than Nano. So, if you want the best results, you have to use both materials.

[Jaz]
I agree with you fully. But what about for lower incisors? Let’s say you’re doing a tooth wear case, and you’re doing lower incisors. Let’s say you’re doing veneering the facial and coming on to the incisal edge to build some height. Now the incisal edge and the facial of the lower incisor is the functional surface. Would you like me shy away from using microfill there? How do you manage that scenario?

[Javier]
Well, you know what I’ve been doing that for maybe 20 years now, composite on lower veneers. Why? Because lower veneers you need a lot of space if you want to do porcelain. I only do porcelain veneers on lower incisors whenever I’m raising the vertical dimension of occlusion. Because then I can have a lot of space, Jaz. But if I don’t have that space, which we never do have that space, then we can do a very thin layer of composite. And most of the times I still do all my microhybrid on the incisal edges. And then a layer of microfill in the front and that will not get any breakage, Jaz. And as was mentioned, microfill composite wears less fast than nano or microhybrid because of the filler is so small that works very slowly.

[Javier]
I don’t know if you remember Heliomolar, which was using for posteriors by Ivoclar? It was a great material for posteriors and it was a microfill composite. And the wear was less on Heliomolar than on their microhybrids because of the filler content. The same thing happens with lower incisors. And I haven’t done a porcelain veneer on lower incisors in so long. I do a lot on uppers but on lowers I stay away from porcelain. Because composite, I can make it even thinner than porcelain and it will last for years. They will be wearing away. I have seen patients that come back 10 even 20 years later with my composite veneers that they had been worn down after that. But they don’t get a disastrous come up when a portion of veneers breaks and then you have to replace the whole thing. So, they’re very long lasting and I would not recommend my colleagues to do porcelain veneers. Think porcelain veneers on lower incisors. Believe me! I’ve been through that, Jaz.

[Jaz]
Will you raise an interesting point about when we have a lack of space and therefore you favor composite in those scenarios? I had this notion that even for composite you need like a minimum thickness for strong and compressive but you still need a minimum thickness. But you seem to suggest that okay, perhaps we can go thinner than ceramic. So, is there a minimum thickness on the incisal edge?

[Javier]
Yes, you need a millimeter. You need definitely one millimeter, okay, and on incisal edge. If you get a millimeter then your veneers will last to 10 years, Jaz, for a millimeter. Of course if you have a grinder or a bruxer then you need a nightguard for those patients definitely, okay? But you will never have a composite veneer break on you. On the lower incisor, you will have it on full static porcelain. But you will never have it in composite. They will wear away years after. And then they come back and you just sandblast and add to them. But you don’t have to replace the whole thing. Which is what I love composites on lower incisors.

[Jaz]
Well, we touched on it already. Now let’s go to the big question of this episode, which is ceramic versus composite. Now, if you don’t mind, I just want to share a little bit of where I’m coming from. And I’d love for you to then take it away here, is that, when it comes to the debate when you’re decided that, ‘Okay, you want to go for an aesthetic enhancement, and you’re coming up to the decision between, should we go composite or should we go ceramic?’ For me, the biggest player is age. Age have a huge consideration for me and the younger the patient, the more likely I’m gonna go for composite. Pretty much all of my ceramic veneer patients have been always above 50. It’s just been my past. I want to know what you feel about that. However, some dentists suggested and the groups that I’m part of that when I posted a case they said, ‘Oh there, there isn’t much enamel. I don’t want to go ceramic. I’ll just put composite.’ And I in my head, I’m thinking well, they both are a decent dentistry. They both need good substrate; they both need good enamels. So, I kind of disagree with that. But I’d love to hear your thoughts on that. So, what is the decision making tree? What are the things that you look at when you’re deciding between a composite rehab and a ceramic rehab?

[Javier]
Well, the first thing is that older patients have a lot more wear on their teeth, Jaz. So, I can do composite veneers on older patients every time that I address their occlusion. If I do not address their occlusion, then I will have problems, Jaz, don’t you agree? You have to address their occlusion. Okay, so what is that we have to have functional occlusion. So, every time that I see one of those older patients with wear on their teeth, I do a wax up, Jaz. And nowadays is so much easier because you can do it in exocad, you don’t even need to wax it up yourself, you can exocad it, you know? And so, what I do on those wax ups is that I give my patients anterior guidance, and canine this occlusion Jaz. And with that, I am guaranteeing myself that those patients are going to keep their teeth and their veneers in well condition for a very long time.

Believe me, if you do anterior guidance, disocclusion and canine rise, you will have functional occlusion and your veneers will last a very long time, Jaz. It’s been a long road. But believe me, if you use the right material, which is microhybrid and microfill, and you use the right occlusion, which is anterior guidance. And canine disocclusion which is brought from the wax up to the patient’s mouth with a matrix AP, a polyvinyl siloxane matrix, or a clear matrix. Then you will get the best of both worlds, you will get the advantage of an indirect restoration with the advantages of a direct one. And I get great success with that every time that I address occlusion. Don’t get me wrong. I still do a lot of porcelain, Jaz, I still do a lot of it. But I see composite as a material that has the same quality as porcelain. I don’t see it as a second-tier material, I see it as a first grade material that I can offer my patients every single day. And if you learn how to make teeth, you will definitely be able to do veneers every single day in your practice. Instead of doing once per month a case of veneers or once a week a case of veneers.

I have some colleagues that say you know what, I can only do one case of veneers per week, because of my lab technician capacity to do them. What if I tell you that I do one case every single day? Because I do them myself or my colleagues here in my office do them themselves. And that is freedom. What every dentist that learns how to make teeth has the freedom to do whatever they want every single day. And not saying to the patient, ‘You know, I’m gonna call my lab to patient and see if he can have the case in two weeks.’ Two weeks with temporaries and then the temporaries fall and then the sensitivity and all those problems. You don’t have those problems with composite veneers and you will get beautiful aesthetics and very long lasting cases. I have done hundreds of cases in porcelain, like I told you I love the felts feldspathic porcelain. But then with cat cams, you don’t get that anymore, you get only very thick veneers. And when you get veneers-

[Jaz]
It’s a dying art.

[Javier]
It is a dying art. And since feldspathic is dying, composite is racing, you said it yourself at the beginning of the of the podcast. Composite is thriving because we dentists feel the need to have control to do conservative dentistry. I mean, when my lab technician told me, ‘You know what, I just bought a $200,000 CAD CAM machine and now you’re gonna have to prep on your veneers, three quarter crowns.’ I said, ‘No! I’m not gonna compromise my values. I’m not gonna do on my patients what I don’t want to be done in my mouth.’ I just go ahead and very likely prep, maybe point three or even sometimes less, Jaz. And I add my incisal edges with microhybrid composite. And then in the front with microfill composite, and they turn out beautiful. They last for a long time. Of course, I have to address occlusion, like I tell you anterior guidance, canine disocclusion, posterior support, and you have a winner. And if it’s a bruxer, and if it’s young is even easier, because you just raised the vertical dimension of occlusion, and they have tons of space. Which we can talk about that as well later on.

[Jaz]
For sure! I mean the immediate thing that I’m thinking already is okay, so you’re obviously a big fan of composite but you play so many porcelain as well.

[Javier]
Yes

[Jaz]
When is it nowadays that you will then consider ceramic ahead of that and then also later do want to touch on, you mentioned about the prepping. Most of the composite veneers that I see on social media are claimed to be no prep. So, they will say on the Instagram description, ‘ZERO injection! ZERO preparation!’ Very proud of it, that kind of stuff.

[Javier]
Yes

[Jaz]
But obviously putting the occlusion aside, I’d love to hear from you about, where does that no .3 millimeter come in? Is that for space reasons, or is that for other reasons? If you just go into that as well, as well as dressing, well at what point I actually go for ceramic then?

[Javier]
Yes, well I still go with ceramic whenever I have very destroyed teeth, Jaz. Whenever I have, class three in between each tooth and class fours and I have a lot of different colors in different teeth and then I have to mask everything and it’s just I cannot fix a smile in the morning, I go with porcelain. But if I-

[Jaz]
In that case, is it the crowns or the veneers?

[Javier]
I do both! I do crowns and I do veneers. And the other thing is that also if my patient can afford it, because if you want to do conservative dentistry, you have to have a very expensive that lab technician, that can do a .4 or .5-millimeter veneer. And I don’t know in the UK, but here in Costa Rica, the lab technicians that can do that charge as much as maybe half of my veneer fee. And so, if my patient can afford it, then I go ahead and do porcelain and if I think that is worth it, like you said, maybe patients that has very destroyed teeth, or older patients then I go with porcelain and I still do a lot of porcelain.

[Javier]
But I was blessed to learn how to make teeth and I’m not a very dexterous dentist. I just learned how to do it. I took a plane, I went to Chicago and took all of their courses that they see in Cosmo didn’t. And then I went to see Dr. Newton files in Brazil. And then I went to see Dr. Oz, California, California and then I learn how to make teeth and they practice and practice and practice and practice. And now I’m a free dentist, whenever I feel to call my lab technician to say, I have here a porcelain veneer case for you, I can do that. But most of the time nowadays after 20 years of practice, I tell you, I do most of them in composite. And I’m so happy and so free because of that I keep doing them and I offer them to my patients.

I also have you know, I’m already 52 years old. So, I’ve been teaching this technique a lot. So, I have a lot of dentists with me that also do it. And they also have seen the value of learning how to make teeth. That also translate in posterior dentistry. I used to do a lot of inlays and onlays on Emacs. And, you know, sometimes it’s frustrating trying to make them fit, you know, the contact points and the occlusion and everything. And then I found out that I could do that directing direct technique also in posterior teeth. And so, now I make full mouth rehabs with tabletops of composite and the posteriors and tear, composite veneers racing vertical dimension in centric relation occlusion, and I gave them anterior guidance and Kennedy’s occlusion every single day. You know, I was like listening to Dr. Patel, you’re invited dentist last month about full mouth rehabilitation and he’s right, you know. If you look closely at your patients, 80% of them need a full mouth, Jaz. Because they all have wear, they all have interferences in the in the back. So, they have wear in the front. And so, if you raise them their vertcal occlusion with just a little bit of composite, and then you give them anterior guidance and cane and rice. They’ll love you for doing that because their problems are gone. Their teeth are not breaking anymore. Their muscles relax in centric occlusion. Their joints are healthier, you know, is such a beautiful time to be a dentist. Jaz, I tell you, you know,

[Jaz]
That’s my favorite thing. I’m always vouching for that. Now is a great time that ‘Oh! there’s so much doom and gloom’ but there’s never been a better time to be a dentist. I’m so glad you said that.

[Javier]
You know I have a scanner now and I look like a kid scanning all my patients. You know, I used to say, ‘No, you know you will never replace polyvinyl siloxane.’ And now I do replace it every day you know with my scanner, you know, so it’s such a great time to be dentist. It’s just a great materials that we have, the adhesive dentistry that you have to believe in. Just forget about metal. Forget about porcelain fused to metal. You know, my you know what my lab technician used to tell me? ‘Javier you have to grind, prep your teeth until you see pink so that I have a lot of space for my porcelain fused to metal.’ You know, and I used to do that, Jaz, I tell you. I’m so regretful because I would never do that, on my mother or my sister or myself. I would never do that. And I used to do it! And now, it’s very rare when I get into denting unless my patient already has crowns, already has big class for restorations. I say yummy. Now, all the time. Either if I’m working with porcelain, or even if I’m working in composite, I stay on enamel because enamel is The High Road as commonly assess. You’re working on, you’re working on a high tear place. You’re working dentin, and then it goes down. You do root canals and it’s even lower biomimetic dentistry. So, if you stay in enamel on vital teeth, you have a winner. And that’s when your cases will last 10-20 years. You know what, Jaz. I’m gonna tell you a secret here. I graduated 30 years ago as a dentist when I was 22 here in Costa Rica. And then I went to the States to do my postgraduate studies and I stayed there for five years studying and working. And so, I can see now my patients that I did some work more than 20 years ago. All those patients that I racked their teeth with crowns, they come back for implants now. All those patients that I was conservative, and I did veneers on them, they come back for more veneers. So-

[Jaz]
That’s a very humble of you. And that’s very good to hear. There’s no better teacher than seeing you on recalls.

[Javier]
You know, time is your judge. And you know I have so much enamel on my back, Jaz, that I’m regretful of doing of prepping all those teeth. I used to brag how my preps were perfect. And I used to brag how many full mouths 28 crowns I can do in a year. And now I regret all that because I know that technology was available. But I didn’t understand it until maybe, what 10 or 15 years ago, Jaz.

[Jaz]
Well, I think I think you’re being a bit harsh on yourself. As you know, Javier, I think, obviously advancements dentistry. You did what was right at the time, you’re practicing through the porcelain deficiency years. The whole everything was veneers, you prepped those years, and now you’ve totally embraced minimally invasive dentistry. And you’re, you know, you’re a champion of that. And you’re seeing that. So, you know, don’t worry about that everyone’s got skeletons in their closets. But it’s a very nice admission of you. So, we appreciate that.

[Javier]
I’m trying to be as open as I can be with you guys. Because I don’t want you guys to go through the same thing as I had been through the last 30 years. You know, which I regret doing some things. And then I find out that the golden rule is true. If you do on your patients what you would do on your mouth, then they will come back, they feel that. They’re not dumb, they know that you’re doing the best for them. And the best for them is conservative dentistry. So, I would strongly suggest either it doesn’t matter what material you guys choose, porcelain or composite. What matters is what are your belief course, your morals. And why it matters is what are your principles of treatment planning. And if your treatment plan for conservative dentistry, then it doesn’t matter if you do use acrylic, because it will work. So, there are times where you have to prep and I still prep, but there are times when you can be conservative. And so, if you see that you can be conservative, then you go ahead and be conservative, and do that every day and you’ll be a happier dentist.

[Jaz]
Totally agree and in my own experiences, I’m not doing so many crowns. I’m only doing crowns and I’m replacing old crowns. But even when I have to do a crown nowadays posteriorly if I’m in with the whole, then if you do much vertical preparations. But the minimal amount of tooth structure can move now to do crowns with featheredge Zirconia is absolutely amazing. But anyway, we digress, we’ve gotten a bit sick.

[Javier]
That’s amazing.

[Jaz]
I’m gonna go back into little details now because we touched on it and I know that Protruserati are hungry for this. Because you mentioned about doing a full mouth composite rehabilitation whereby you’ve got the beautiful anterior veneers with the microblade with the microfill on top and then posteriorly, you’ve got your composite tabletops. Now it other, do the rules change a bit here now? Are you aiming for more thickness of posterior composite here than on the anterior? Or is it have you found success with one millimeter still because you’re remaining in enamel? I’d love to know that.

[Javier]
Well, for your YouTube fans, Jaz, I would like to show you this prep,. I was so proud of doing this kind of preps Not anymore. Now I show this like showing a wreck, you know. Now I love to be conservative and I love composite resins because I can be as conservative as I can, you know. And so, let me show you for your YouTube fans, a little bit of what we can do. I’m showing here, Jaz, a patient that came into my office that had a gummy smile, you know, she told me, ‘You know, Doctor, I have a gummy smile.’ And when I look at her mouth inside, inside of her mouth, I could see a lot of wear. These are a lot of patients that they’re in their 30s. And they have a very vibrant life. And because of stress and because of grinding, they have worn down their teeth. And as you can see here in the pictures, we always ask ourselves, how much can we lengthen teeth? Should we lengthen it to the gingival or she will lengthen it to the incisal? It depends on their rest position? If the rest position they show less than three millimeters then we can lengthen them incisally.

[Jaz]
Javier, let’s make it really tangible because I’m loving this so far. But for those watching young dentists, some dentists are learning photography and they think they don’t know how to get a good rest photo. So, what do you say to your patient to get a good lip at rest?

[Javier]
That’s a great question, Jaz. You know, I’m having such a great time with you. You’re asking the right questions. You know, you just tell your patients say, “AH” they will show this picture right there that are you see, she say, “AH”.

[Jaz]
Amazing. That’s a great one. Another way to do it is “Emma, Emma”. And another one is just drop your jaw. So, if you just drop your lower jaw and they just open a little bit, that’s another way and they might produce slight differences, but you get near enough to ballpark. Thank you.

[Javier]
Exactly! And that’s just a great tool because then you’ll know that you can maybe lengthen this patient, maybe one millimeter incisally. But then when she smiles, BOOM! Look at how much gummy tissue she has, Jaz. When she has so much gum showing then you do your digital smile design. And you see that for you to have good ratio width to length ratio, you’re gonna have to lengthen those teeth. Both gingivally and incisally. So, I still use a Facebow transfer. Now with my scanner, I use a transfer that is digital, but I still use my articulators. I still do, you know, a wax up and aesthetic wax up, I still do my Lucia jig, you know, to take centric relation. And then I can take a centric relation record in the posteriors, I do an aesthetic wax up first with my mounted models. How do I do that? I literally smile design my patients. And I measure the incisal edge to the cervical and I add so that I have a good length to width ratio, which is usually 80, 75% on women. And then I do a wax up. With that wax up, I first do an aesthetic one, I do a mock up. And with that mock up, I know that I have a winner. As you guys see YouTube can see here, you can see on the left the patient before on the right the patient with the with the mock up in place. And that is going to tell us how much we’re going to lengthen the teeth. Once we have that, then we can transfer with the matrix with composite veneers on the anterior teeth. So, I usually do first the gingival surgery, okay. Wait three months to heal, I take bone out whenever I don’t have those three millimeters for your biological width. And then once you do your gingival surgery, then if you do composite veneers then you transfer it with your polyvinyl siloxane matrix

[Jaz]
Is this just a palatal? Is this the palatal and then your-

[Javier]
This is just a palatal one.

[Jaz]
And do tell us about your experiences or views on injection molding which also seems to be going quite a huge intake as well.

[Javier]
It is very very popular now. And this is another matrix. If you’re looking at it, you can do this, use this matrix for injection technique. Or you can use this one for your direct indirect technique which you only use it for your incisal edges and then you put on the front some microfill composite. So, let me show you both techniques, Jaz. I have a here for anterior teeth. You know you start with the upper anterior whenever you’re doing a full mouth, you add incisal edges and then you put microfill composite on the front and then you polish. And then you have you have your upper six veneers, you know on your wax up, you already wax up the anterior disocclusion and the canine rise.

[Jaz]
And again, if you don’t mind me stopping in your tracks. As you are what you’re describing it. So, just to make it really tangible for those listening as well, when have you just put the palatal putty stent so he knows exactly where he’s lengthening the teeth to. And I just want to know Javier, in your protocol, are you first putting microhybrid as your first palatal layer for strength? Or are you happy to put your microfill there for an upper incisor?

[Javier]
No, you always need microhybrid on your incisal edges because it’s the strongest material that you have. It’s even stronger than your nano or spherical or microfill composite. So, I would strongly recommend on incisal edges, microhybrid and then you can layer in front for your buccal aesthetics, you can layer it with your microfill composite.

[Jaz]
How many mil we’re talking with the microfill 0.3 and 0.5.

[Javier]
If you’re not changing color too much, you can do point three. If you’re changing color with point five millimeters you can go from A3 to B1. It’s amazing how much you can change the color of a tooth with such a small amount of composite. And if you have a dark tooth, you know that that has a root canal, then they you can use pink opaquer, which is an opaquer that covers grayness. So, if you have a gray or dark tooth, you use pink opaquer first and then your microfill composite. And so, every time that I have a dark tooth, I just prep a little bit more than that tooth, so that I can put an opaque composite like this pink opaquer. And then I go with my microfill. So, continuing with the full mouth, you go ahead and do the lower teeth, you take again, the matrix, you first place in the incisal edges, your microhybrid composite, and then on your buckle, your microfill composite, and then you check your occlusion to have anterior guidance and canine disocclusion. And then on posteriors, you can do the inject technique or you can do also direct indirect technique. What I usually do is that it on posteriors, I use a clear matrix, which I heat up microhybrid composite with a composite heater, and then I put it on my matrix and then I take it to the mouth and light cure it, I do it at a tooth at a time. But those are great, great onlays that you can do with microhybrid composite, and a clear matrix. This material-

[Jaz]
Like Memosil or Exaclear

[Javier]
Memosil from Kulzer’s great. This one is called RSVP by Cosmedent, or Zhermack. I don’t know if you know Zhermack materials, they have a great material, a clear matrix material like this one, which is great. I use tints so that my my anatomy shows and it looks better, you know, like brown tint or oprah. And so, you can go with teeth that are flat and worn down to have a great onlay just with microhybrid composite. And then you can check your occlusion, make sure that you have points in the back. And whenever they’re going to protrusive movements, they will have lines in the front, anterior guidance, and canine rise is so important. I cannot stress that as much. So, you can do a full mouth rehab, Jaz, with composite and you know, on those young patients, 30 something, 40 something that they don’t want crowns and that you know, I get them all the time. You know, you’re the third dentist and I’ve been offered 28 crowns, and they don’t want that because their teeth are still. They still have maybe 50, 70% of their tooth structure and without prepping you can open that vertical dimension of occlusion and you can full mouth rehab a patient without taking off an ounce of enamel. And that’s what’s valuable about dentistry nowadays. You can give your patients function and aesthetics without being a grinder.

[Jaz]
I mean, the etiology is also important I think there’s a difference between a primary erosive case and a primary attritive case. The forces, I mean, for a lower risk patient lower headache for dentists you want to be treating that primary erosive case because the functional demands that there may be lower than the primary attritive. So, that primary attritive patient will be producing higher forces and although we do our material selection, and we believe in the composites and we get the right thickness, minimum thickness, the correct type of composite ie microhybrid. Just like you said the beginning, some patients, whatever they did their own teeth will put the same high forces through the resin and therefore an occlusal appliance, you know, you can do all the beautiful excursions and canine initiated exclusion. But some patients with the large masseters and history of destructive forces need an appliance I think.

[Javier]
Oh! Definitely they need to have a nightguard. But another thing that I found out, Jaz, is that I used to do a lot of gold, metal, a lot of Zirconia. And then I found out that it’s not that you need to put something stronger than their own teeth in their mouth, you have to put something that is he has this exactly the same strength as their enamel and dentin. And you know what? In Zirconia is very, very tough on teeth very tough on occlusions, like that. And then I don’t see broken restorations, I see broken teeth that I need to extract, you know, after putting very tough materials on patient’s mouth. So, nowadays, I think about, what is material that will live with my patients for a long time and that will not harm their teeth? Put in something so strong, that they will break their own teeth. And I don’t know, if you’ve noticed that we used to prep so much teeth and maybe porcelain fused to metal, and then your restoration will last for a long time. But what breaks? It’s the tooth inside, and especially if they need a root canal.

[Javier]
So nowadays, you know, whenever I’m treatment planning for a full mouth. And I see some teeth that already have root canals or already has, they have root cavities, root decay, those teeth, you better replace them with implants before you go ahead and try to be a hero. If you want, I mean, your restorations, Jaz, are gonna last a long time. Even if you do them and porcelain or composite or Zirconia or gold, what will not last a long time are those teeth that are already very badly broken, or badly used, you know, like with root canals or deep cavities in between teeth, you know. So those teeth, you might as well treatment plan them for implants before you go ahead and try to be a hero. But if those teeth are healthy, don’t grind them down. You just add to them whenever you need, you can do that. I do a lot of those cases, whenever I have maybe 20-30% of enamel loss because of wear, either because of acid in their mouth, because they bulimic, or because they drink a lot of cola. And those cases, you just clean everything up, you use a rubber dam, and you microetch them with a sandblaster and then you can bond to them very, very successfully. Of course, you always have to refer those patients to the gastroenterologist so that they take care of their stomach problems, or to the psychiatric, if they have bulimia, you know, that’s a very common problem here. So, you have to first, be a doctor and look at them in the eye and said, ‘You know, I can fix your teeth, but you first have to solve your problem. And you have a bulimia problem. So, you have to solve that because if the teeth that God who is the Mighty One, gave you they worn down, of course the veneers that are going to place are gonna go away as well. Because the problem that you have comes from your stomach or comes from your brain, and you need to get help.’

And those are things that we can help our patients so you know what, I have some patients that they come back from the doctor and say, ‘You know what, Doctor, I had this, I have this huge ulcer that I didn’t know. And now I’m gonna have to go into surgery and it was showing in my mouth’, you know, or ‘Doctor, you know, I’ve been going to the to the psychotherapist and you know, I have stopped with the bulimia problems that I had, and I’m very grateful so now I’m ready to fix my teeth.’ And so, it’s like I told you before, Jaz, its a beautiful profession. it’s a great time to be a dentist. You know, you know I wish to have three kids, you met my past. I wish the three of them were dentists, one of them doesn’t want to be a dentist. It’s okay. But I recommend them everyday to be a dentist because we can help so much people hear anything anywhere in the world with dentistry. You know, we are doctors of the mouth. And this is such a great time to help people that they are stressed and they’re wearing away their teeth with either chemicals or forces that are in the wrong time and the wrong position.

[Jaz]
Very well said. And I echo all those sentiments. I’m gonna go into again, Geek mode now. Before for a general discussion, and the geek in me is going to ask you a question that the Protruserati are definitely hungry for because something that we’ve discussed on our protrusive dental committee Facebook group many times, which is interproximal management. I’m a mylar pull kind of guy. And I know Pascal Magne in Edinburgh recently, he is a big fan of PTFE. And just taking the composite right up to the PTFE. And he’s some sort of wizard like that. What is your recommendation? What is your protocol for interproximal management to prevent the composites being stuck together and getting the nice smooth flossible interproximal surfaces?

Jaz’s Outro:
There we have it guys at my friend Dr. Javier Queiroz. Amazing composites, you must check out his work. I put all the links in the show notes so you can check out the courses he does, and the kind of cases that he’s presented. Of course, the YouTube people do get a little bit more advantage. But I made sure that any parts that aren’t clear to my audio listeners who are the original Protruserati, I will always make sure that your listening experience is not hampered in any way. So, make sure that anything that was too visual, I took it out and I just stuck it on the video elements only. Do join us next time for part two with Dr. Javier Queiroz. We will discuss the interproximal management. I left you on a bit of a cliffhanger there. We also discuss isolation techniques for composite veneers. How to prevent those dreaded stains? And what are the five Ps of composite veneers. And hey, thanks so much for listening all the way to the end. If you’re one of my listeners who always listens all the way to the end. Thank you! If you haven’t already joined splint course, do consider joining. it’s actually as a podcast as well because I realized that in our busy lifestyles, where do we make time for laptop education, right? Because that’s the kind of course it is on demand online course. So, to make it more accessible, I’ve also got it as a podcast and then use a video as a reference. So, if you haven’t checked out already, check out www.splintcourse.com and enroll today. I’ll catch you the next episode guys. Thanks so much!