NITTY GRITTY Composite Techniques PART 2 – PDP120

Jaz’s Introduction:
Protruserati is a dentist who listen to his podcast, but then finds themselves scrolling and then listening back to the old podcast that they haven’t listened to before. And suddenly you’ve binged a lot of the episodes and therefore now you are a loved Protruserati. It means that you’re passionate about dentistry or you want to be passionate about dentistry and you like tangible, productive tips and pearls to help you on Monday morning. So what I like to do with the podcast and what’s evolved to become is a fun way to share. I’m hoping that most of the episodes you listen to aren’t boring and there’s a bit of humor or lightheartedness. We discuss real world dentistry or tips and themes that are really relevant and you can apply on Monday morning. So in this part two you’re in for a treat. Like if you remember the three episodes we did with Dr. Devang Patel, let’s go back and listen if you haven’t already, they were on a ADHESIVE FULL MOUTH REHABS in three episodes. So how to do from right the beginning, from zero to 11 appointments over three episodes, how to do adhesive full mouth rehabilitations? So as we got more and more towards part three, it became MORE CLINICAL, it became MORE PROCEDURAL. And to this episode is no exception.

So Dr. Javier Queiroz becomes a bit more procedural in this episode into a nitty gritty. So in this episode, Dr. Queiroz covers INTERPROXIMAL MANAGEMENT OF COMPOSITES. I left you on a bit of a cliffhanger last time if you remember, sort of about isolation. Is it always necessary to use rubberdam or even split dam or OptraGate like personally? For a lot of anterior bonding, I like to use the OptraGate. For my posterior especially lowers, I will use rubberdam. Lower incisors, I’ll definitely use rubberdam. So for me it’s it’s variable and depends on the patient very much. So let’s see what Dr. Queiroz has to say about that. PREVENTING STAINS. That’s a huge one, right? So you’ll hear from him what the protocols are to prevent stains and composites and the FIVE P’S OF COMPOSITE VENEERS.

This episode, once again, is kindly sponsored by Enlightened Smiles, who also are the ones that sell the CASI instrument which I talked about in part one. So in the UK, they distribute, otherwise Cosmedent products are brilliant. So if you’re in the US, you know go to Cosmedent. If you’re in UK, If you want the Cosmedent products you go to Enlighten and Enlighten who’s sponsoring this podcast. So, do show their support for supporting me.

Protrusive Dental Pearl:

Every episode, as you remember, I give you a Protrusive Dental Pearl and for this episode, I’ve got a really good one. I need to pay homage to Dr. Pasquale Venuti, the Don, Pasquale Venuti and Dr. Marco Maiolino These are both amazing dentists from Italy. In fact, I have a whole series with Dr. Pasquale Venuti coming very soon in a couple of episodes time, it takes a long time to edit some of these episodes. So Pasquale is brilliant, I want to do it justice. So please hang tight and wait for this epic amount of educational goodness coming your way from the Pasquale. But one of the things I learned from their vertical course online so Verti Preps online. I’ve done Verti Preps courses with three different educators now. So Andre Cardoso, Portugal, Jason Smithson, UK, and the Italians Pasquale Venuti and Marco Maiolino, you know, I am biased towards vertical operations. I still do the horizontal, and I do lots of onlays.

But for a lot of crowns, I will do vertical preparation. So one thing I learned from that course, and it’s like one of those tips, I think, ‘Wait, why didn’t anyone show me this before?’ And maybe you guys already know it, I don’t know. But I’d love to share this with you. So let’s say you are making a direct temporary crown using a bis-acryl material, Luxatemp, Integrity, Protemp, you name it, right? So you fill in your putty, and then you make the temporary crown, and then you take it out and then you trim it with a soflex or diamond to make sure it sits on perfectly. Now, a lot of the time when you are polishing or adjusting the interproximal mesial or distal, let’s say single crown mesial-distal contact areas, you’re trying to make sure that you can re-insert the crown right because if you can’t get the crown back in, then you have to do some adjustment interproximally. So, you do some adjustment. And now you find that yes, the crown, your temporary crown is sitting fully, and it might be happening in the bite, etc. But now there’s an open contact mesially and distally. Now, yeah, hopefully there’s enough occlusal stability that the adjacent teeth will not tilt into the area. But we really miss out on a big benefit of having nice height contacts on temporary crowns. Because temporary crowns, well, they’re temporary, okay, and they can come away. So you know, your patient goes away for a few weeks comes back, I can hear all the cerec dentists laughing at me now. But anyway, your patient comes back. And sometimes you know that temporary crown is lost, and it’s not nice, we want our patients to keep the temporary crowns in their mouth, that’s the whole point of giving them a temporary crown.

So if you have an open contact, mesial, distal or medial and distal, then you lose some retention in a way, right? When it’s nicely snug against the adjacent teeth. It is much more secure. But when you have open contacts, it’s relying so much more on the cement, on the resistance and retention form of that crown. So, how can we, this is the real tip now. How can we POLISH OUR TEMPORARY CROWNS, but at the same time, ensure we DON’T OVER POLISH and end up with open contact? So, this is gonna blow your mind. Because I was like, what the hell? Why is it so simple? Why didn’t anyone teach me this before? So, maybe it’s just me. So, when you take out your bis-acryl temporary and you just about prise it out, sometimes maybe you get a flat plastic and you bring it out.

Now the first thing I would do is I will get a either a Sharpie pen or an indelible pencil and color in a small circle, maybe about 2-3 millimeters, mesial and distal, okay of where my contact area is. Where it’s contacting the mesial and the distal tooth. Now that I’ve colored that in, I’m not going to touch that, ie, I’m going to do my soflexing, diamond bearing, acrylic bearing, or however you want to polish your temporary. I will do it but I will not touch that penciled mark. So, now you’ve got a nice trimmed, polished temporary, but you’ve got a contact area that’s preserved, mesially and distally, which is brilliant, because now you’ve got a nice, tight, snug fit. That’s not overly tight, but it’s nice and smooth as well. So this is my big tip passed on from these Italian guys. Such a simple one. I hope you use it. Like please use it like next time we do a temporary crown, do it. Because it makes so much sense. And you’ll see wow, why didn’t anyone teach me before? So like I said, maybe you already know this, but I didn’t. Let’s join Dr. Javier Queiroz and I’ll catch you in the outro.

Main Episode:

Because it’s something that we’ve discussed on our Protrusive Dental Community Facebook group many times, which is INTERPROXIMAL MANAGEMENT. I’m a mylar pull kind of guy. And I know I didn’t see 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 stacked together and getting the nice smooth flossable interproximal surfaces?

[Javier]
Well yes, I love that pull through technique and the pull through technique. It was taught to me by Corky Wilhite at Chicago CE, and it’s such a great technique that I use it every day. So what we do, let me show you right here.

[Jaz]
Show it and then you described it for the listeners as well.

[Javier]
Yes, I’m showing a video here real quick for those YouTube fans. You place first the incisal edges with the microhybrid. Okay, like I showed you before. And then whenever you’re going to close a gap or a diastema. Then you put a mylar strip, then you do a little sausage of composite in between your fingers. Remember, you have to have in between your fingers, the anatomy that you want to bring, if you want to bring a contact, you have to do it in your fingers before you put it in the mouth. You cannot put it in the mouth and expect to become something you have to do it in your fingers with very clean gloves and then put it in the mouth, okay, and then you put it on the mylar strip. And as you can see there in the video, you pull in lingually and then that composite will go in between each tooth, and then you take off all the any excess with your IPC thing instrument. And then you put back your mylar strip, and then you can like cure it and you’re going to get a very strong and durable contact in anterior teeth.

Okay, and that’s called the Mylar Pull Technique. And they use it every day. And it gives me great, great, great results. You know, whenever you you’re getting stains in between teeth, because in your composites is because you’re not getting your composite all the way to the contact. You’re just leaving your composites shy to the contact and then you will see that line or that stain in between your teeth. And whenever you do this technique, then the composite will go all the way to the contact and it’s going to give you a much stable, color stable composite veneer. But it also is going to give you a tight contact. So you will not get food in between your teeth. I mean, that’s the best way to do it. And and it’s called the Mylar Pull Technique

[Jaz]
We’ve talked about it before. And I’ll add a link again to some of the videos that we’ve shared before about this technique. And yeah, our big fans want to hear what you thought about that technique? And sounds like obviously, you’re a big fan as well, yes. Now, the floor is really ours in terms of where we’re going to take the rest of this episode. Are there any key points to get great results, I know you’ve got finishing and polishing there, which is such a huge part of everything we do. What are the jems that you want to share with the Protruserati now?

[Javier]
Okay, so the five P’s of composite success is five P’s. The first is Patient, make sure you pick the right patient for composites. If your patient is a smoker, if your patient tells you, ‘You know, Doc, I will never get my teeth clean. I just want my veneers and get out of here.’ Then you go for porcelain don’t go for composite, you know, but if you have a patient that has great, or good oral hygiene, then you can go with composite every single day. You know, your patients that you already have in your office, they come every six months, those are your perfect patients for composite veneers, then Preparation and isolation, make sure you use a rubber dam. It’s so important to isolate, you know, it’s maybe 90% of your success is because of your isolation, then the number three-

[Jaz]
I just want to stop your isolation if you don’t mind, Javier. Because those who are listening may not have seen the cases you’re sharing it sounds or looks like that you are preferentially going towards split dam technique, because obviously, when you’re doing veneers all that gingival margin, it’s very difficult to actually go a normal full rubberdam. So am I right saying that you’re doing split down technique?

[Javier]
I do split dam technique because I don’t like to do individually and then go clamp by clamp because I sometimes get bleeding. And like I told you I’m not such an agile dentist. So I do split dam technique. And I’m showing a video here on how I do it. And it only takes me two minutes to place it. And you know what I do in the posterior then I close it with a putty in the palate so that I will get total isolation. But I have a great area where I can work with and is amazing the amount of isolation that you can get with an open or split dam technique. But as I’m showing here, you can always close the back of your palate with putty. And that gives you total isolation Jaz, and oh my god, I keep fighting you know, I keep fighting with my associates. I’m walking in the hall and I see somebody doing bonding without a rubber dam. You know, I freak out Jaz. I’m such a control freak.

[Jaz]
We’re the same. I can’t do any of adhesive dentistry without Dam.

[Javier]
You know, and I used to bite the tongue and fight the cheek. And you know, now it takes me two minutes, two minutes to place the rubber dam because we develop that practice. And those two minutes saved me like half an hour in every procedure. And I used to do a lot of porcelain inlays and the you know, the ones that I cemented without the rubberdam on, you can always see that line on the inlay, you know, a year afterwards, you know, like you have adhesion, but that’s not good adhesion, those patients that I put a rubber dam and I bond with the rubberdam you cannot even tell where the line of the inlays is that you know. You get total bonding when you have total isolation. So I definitely recommend you guys if you have to take a CE course you know Jaz, you and I have talked about before which CE courses should we take? And you know it sounds very basic, but take a course on isolation. You know I have learned so much on those courses on isolation and my dentistry has gone from mediocre or medium to top dentistry because of rubberdam techniques.

[Jaz]
So 100% agree and I just want to comment on one thing I just saw on your video, which I don’t do but I’m totally gonna do now is that random tissue that you put underneath rubberdam? I mean why I don’t do that? I mean this sounds like an obvious thing to do but I’m gonna start doing that, so is it just like a normal-?

[Javier]
It’s normal. It’s a napkin. It’s a tissue paper, Jaz.

[Jaz]
You just cut the corner. Cut one corner when it’s folded and then it becomes a big circle. Yeah,

[Javier]
Yes. I used to, there it is, there is in the screen so for those youtubers, you can see it right there. You know, I my patients, whenever I took off the rubberdam, most of them have some kind of allergy to latex. So then they have this rash on their faces. And they’re uncomfortable while I’m doing this. And I’ve been doing this for maybe 10 years I kind of napkin and then make a hole in it and then I put it underneath the rubberdam. And then when I finished, they don’t have any problems on allergies and all that. So, whenever your patients tell, ‘You know, I’m very sensitive to latex.’ This is a great technique.

[Jaz]
Awesome. Thank you.

[Javier]
Yeah, yes.

[Jaz]
Please to the 5 P’s. Sorry for interjecting.

[Javier]
Yeah, the Polymerization you know Jaz, those $75 eBay curing lights will not do for you. We’re all tempted to buy those $75 curing lights by you need a first of all, you know those expensive curing lights they have all the wavelengths that you need for every single material. Either if it’s dual cure or light cure or any material that data light. So you know VALO is a great curing light, 3M , the new one is great curing light. Bluephase by Ivoclar is a great curing light you know, all those curing lights, I’m sorry to say they’re expensive, you need to have them. At least one in your office. Why? Because then you can layer and cure for five seconds, layer and cure for five seconds and then at the end, you like your for 40 seconds per surface at the very end with this high power curing lights. And then when you polish up this veneers, you’re going to notice the difference between well-cured composite veneers and and poorly cured composite veneers. So if you have one of those or if you still have your curing lights from dental school, it’s time to upgrade.

[Jaz]
I’m actually a big fan of testing. I actually, now and again, I will test my light cure because I’m VALO user and I went around testing so we have the main brands, the 3M one, the VALO, which is good but if you test a cheapy like you’re on this tester I have, the wavelength and the power it is way lower and you can notice it on these tests as well. So you’re great point. Well made.

[Javier]
Yeah, curing lights you know is not a big deal. I also try to get rid totally of the oxygen inhibitor layer at the end. So I put some glycerin around my veneers at the very end. Once I cure in, I put some glycerin and then I cure in again, you know, and then I find out that I get less staining in between teeth. And I get less, I get better polishing because I got rid from the beginning to the oxygen inhibitor layer. Jaz, I don’t know if you if you do that or if you like to do that?

[Jaz]
Yep, KY jelly good old Amazon bought KY jelly. Just make sure your nurse doesn’t call it KY jelly. But yes, we use the k gel as we call it. And yeah, cure over that and definitely all those reasons, the polishing ability, the full cure is worth it.

[Javier]
So the number five P of composite veneers is polishing. So you have two steps. The first step is finishing and you’re going to finish your veneers first. I use a brush at the end with my microfill composite. I place it with my IPC and then I use a brush, wipe the brush, because the brush will give me a very, very close surface to what I want to achieve and you can see it here on the screen and that brush makes the tooth smooth but then I go ahead and take my ET burs, they are great carbide burs, I have nine blades and 12 blades. I go with the nine blades first and then I started with the finishing procedure which is taking care of all the lines and make sure that you give some good anatomy to those veneers when I finished my veneers-

[Jaz]
What speed are using this at? So you got the carbide, at what speed?

[Javier]
At the beginning, very low speeds. Maybe 3000 RPM, something like that very low okay. And then as much as I go I didn’t go higher and at the end I go very high high reps. So if you guys are looking at the video you can see that I already have my line angles achieved with my microfill composite and with the brush. So I tried to be very close with my anatomy with the placing and layering. So that when I finish, I only do very minimal adjustments. So I start with my Et burs and sometimes if I want to have some kind of texture I use a fine grain diamond. Okay and I use the nine blades and the 12 blades and then the last step of finishing is my course this which in the in the Flexi discs by Cosmedent is the blue one, I think on the 3M discs is the brown one, and then you start to taking off all the lines, you start getting rid of all the little holes and the things that shouldn’t be there.

And at that moment, if you see a little spot you know like a little hole or sometimes you see a piece of dust, then you go ahead and take a diamond, take it out, put some bonding resin. Do not light cure the bonding resin and put some more composite on top of it and then finish polishing it because you don’t want to have those mistakes showing up at the end. Okay, this is the last step of finishing. It’s called finishing because you’re making sure that you have the right anatomy and the right texture. Once you’re done with this blue disc which is the course disc or brown disc then you go ahead and keep going the other discs, this is like polishing wood. You know if you polish wood and they tell you you know you have to use all the grids to get the right amount of shyness on your wood and you skip a step then it will not look good at the end. You have to go through every single disc to make sure that at the end, you get a beautiful beautiful glass see looking veneer which is what we want so you will not get stained and that’s what patients want because they will look shiny. And that polishing ability of the microfill composite will keep your veneers from staining.

So if your patients come to your office every six months or once a year, when you look at them, they are not dull, they’re still shiny and it’s because of this procedure of taking the blue disc, then the yellow disk then the pink disk then what we use at the very end, we use a aluminum oxide paste with a buff and you go through them first at very low reps and then a very then with water at very high reps but with water because you don’t want to overheat your composite.

[Jaz]
How do you stop the water from splattering everywhere?

[Javier]
You know, I place napkins on my patients eyes and I put some glasses and yes it’s messy. It’s messy. And I tell them-

[Jaz]
Okay, it’s not just me.

[Javier]
‘I’m giving you a second shower today but it’s worth it because then you get a beautiful like I tell you surface on your composite.’ And you know what, you can control the glazing on your composite. You cannot control the glazing on your veneers, sometimes your porcelain veneers, you get that grainy looking veneer that tells you immediately that is porcelain that is not enamel. And you can control that by polishing your composite veneeras to make it look like an enamel, which sometimes if your lab technician and they didn’t do a very good job, then the texture of that ceramic will look artificial will look grainy. And that’s something that I found out that that is very hard to control. Nowadays with the new points and cups that you have for polishing ciconia and Emacs, you can get better polished ceramic than before, but it’s still harder to do than when you do composite.

[Jaz]
You’re relying a lot on the lab again basically.

[Javier]
By far easier, easier to polish than porcelain, so that those are the five P’s of composite success. Like I told you, I always do the smile design first, then the wax up, then I transfer the wax up with the matrices to my patient’s mouth. And then I layer freehand anterior to the buccal part with microfill composites and then we polish and we can go with- I use that technique every single day, Jaz. So, we can do that technique for a class four or to close a diastema. Or we can do that technique with also a full mouth rehab of 2018. So it’s something that we use every single day. And now, nowadays with digital dentistry, we first digitally design it and then print it out. And then you make your matrices on printed models as well. So like I told you, you can do it both ways either in the mouth or-

[Jaz]
It’s very exciting. Now before I ask you where we can learn more from you and how you can reach out more to you, I just want just touch on one thing, which you piqued my interest that you said with the digital, you’re doing the digital facebow transfer. Now please tell me about that. Because the way I do a lot of my dentistry when I’m doing digital is I record my bite at the desired OVD in the arc of centric relation, and then I rely a lot on the photos and I tell my technician, okay, lengthen this tooth by one millimeter lengthen this tooth by 1.5 millimeter, and based on the facial photos, and the side photos, so they pretty much have a digital patient, but that quite often I will not do a facebow transfer, I will get the patient in temporaries and then I’m happy to adjust that temporaries and then many months later I will then convert to ceramic based on using the TMJ as the articulator but my experience of using an actual digital facebow transfer, please tell me more about that.

[Javier]
Oh sure. Whenever I have a case, I do digital DSD and the DSD is just, it’s just a great way to make sure that your patient, first of all, see what they need. And also it’s a great tool for your lab technician. As you can see here, I have this app, which is called Smile Design Pro which I use it every day, you know, and it gives me the plane of occlusion and any comparison with the bi pupillary line. So that I showed this to my lab technician and this gives me my anterior tilting position of my smile compared to my patients eyes, which is the aesthetic part where you need a facebow. The functional part that you need, why you need a facebow is because you need that arc of closure Jaz and I’ve heard it on your podcast a lot of times which is so true.

Every time that you’re doing posterior teeth and you don’t use a facebow you’re running the risk of day being very high. That’s why little hinge articulators are so small, so that angle is very small, it’s smaller than your head and so that you never get a high occlusion. Whenever you have a semi adjustable articulator they are exactly the same size as a head so that you get with a facebow transfer that arc of closure so you will get a good bite. Okay, so I can do it either with my I use Denar articulators just like Dr. Patel. I think Dr. Patel uses Denar

[Jaz]
Yes, he does.

[Javier]
Yes, we love Denars here. And that-

[Jaz]
You’re mixing digital with analog. Right. So you’re taking analog Denar Facebow, and you’ll just adding it to the printed models, right?

[Javier]
Yes, exactly, exactly. With my digital smile design, Jaz, okay. But if you want to, you can also use a fox plane Jaz, you can put it on your patient with some putty, and you scan that, that fox plane, and then you take it, you send that to your lab technician, you know, a scan of the Fox plane. And so they will have that with a putty matrix, so that they can see that the big problem that we have now with digital dentistry is that most lab technicians don’t know. You tell them about the plane of occlusion and they don’t understand that. And that’s where we have to educate our lab technicians so that they can take in our digital scans, but make sure that they also follow our instructions with what quite a facebow would do.

[Jaz]
Amazing. Javier, you answered so many big question. We could talk for days about this, right? There’s so many nuances. Where can we learn more from you? Look, I know you do some education as well. You’re just very experienced. How can we learn? All the Protruserati really enjoyed your presentation. Where can we learn with you, my friend?

[Javier]
Well, you know, I told you I learned a lot at school but a lot on CE. Continuing Education is the basis of every single dentist and you know, I took all the courses from Cosmedent in Chicago. It’s cosmedent.com Jaz. My Instagram account is javierquirosdds. And you can see my courses that I teach at Cosmoedent. Now, I’m so proud of being one of their instructors. I would never dream to be with such a great team of people go to cosmedent.com and go to Courses, continuing education courses and you can see the courses that I teach there. We teach a course on full mouth rehab, we teach a course on posterior restorations. And you know the one that we that we’re going to teach next is called become a cosmetic dentist with composite resin veneers, Jaz. And thank you very much for this timing. You know if you have any more questions, I’ll be more then glad to

[Jaz]
Amazing. Well, I think it’s great that you credited your mentors early on. And you said like, you know, you learn so much. It’s amazing to go that full circle again and then be able to give back via Cosmedent, our lovely photo there is that bud Mopper.

[Javier]
This is buddy Mopper with me 30 years ago, this is 1992, 1983.

[Jaz]
You look so baby face.

[Javier]
And he was, I know, he was my instructor. He was my instructor at Baylor College of Dentistry when I was taking Prosth program. And that’s where I learned how to be-

[Jaz]
He would have had a huge influence on you. Every guest I speak to, when you go back in their story and why they do the type of dentistry that individual dentists does, you find along the way that they were at a clinic whether dentists love complete dentures, or they were taught by this person who’s known for this thing, and then the influence just carries on. It’s like having a great teacher. It’s like having a great math teacher and then pursuing maths for the rest of your life.

[Javier]
Exactly! That’s another thing that I can tell young dentists that are listening. Please find a mentor. You know, Doctor Mopper is one of my mentors. Dr. #### is from Mexico is another one. And you can find so many of them. Dr. Mopper taught me he sat down with me and hold my hand. Can you believe he did that? He hold my hand to teach me how to make a tooth. And it was such a lucky break for me that 30 years later, I’m teaching and I’m trying to give back a little bit of what he taught me.

[Jaz]
Amazing! Well, you make your own luck and you put yourself in those positions and everything you do. So, I’ll put the link in the show notes for Cosmedent. I don’t know if you know this podcast is actually very kindly sponsored by Enlightened Smiles and they’re the sole distributors of products in the UK as well which is a great little marriage here. So, little plug for them always appreciate their support.

Jaz’s Outro:
There we have it guys. Thank you so much for listening all the way to the end. Listen, if you’ve found value from this episode, please thank Dr. Javier Queiroz. Check out his content. Check out his courses. But also if generally you are quite liking the Protrusive Podcast it really helps you know the podcast if you on Spotify or an apple leave a review you know it really means a lot to me I read every single one. So thank you so much for listening all the way to the end. You are a true Protruserati. I’ll catch you the next episode is Carlos Sanchez. It might be that one or it might be asked you as we’ll see how it goes for timing because my brother in law is getting married soon so times. It gets a bit busy sometimes so we’re gonna do additive equilibration with Dr. Carlos Sanchez. Will do an #AskJaz and then the big one with Pasquale Venuti, so, so, much good stuff to look forward to thank you so much, and I’ll catch you soon.