Vertiprep Revision and How To Go Digital for Vertical Preps – PDP089

Jaz’s Introduction: Hello, Protruserati. I’m Jaz, Gulati. Welcome back to another episode of the Protrusive Dental podcast. Now this was supposed to be if you listen carefully to the outro of the last episode. This is supposed to be the basics of occlusion as part of the bigger picture, splintember series continuing on from the back to basics episodes from August which I hope you really enjoyed. But the problem is this man, it takes a long time to script my solo episodes. Like if you if you think back to September last year, so September 2020, we did the splintember series. And, man, I forgot how much effort it takes to put something together, but I’m still determined and keen to put something together, that’s gonna be you know, while you’re commuting, while you’re chopping, onions, gardening, whatever you’re doing to make it a really valuable episode, all about my perceptions of occlusion, and just the very basics from like centric relation to freedom in centric, to when to conform, and when to reorganize, and what all these things actually mean. So I am working on that. And I’m going to get it out to you very soon. So that’s why it’s been a bit of delay, in case you’re wondering. But today, take nothing away from this absolute gem of episode think of this way like I’ve delayed basis of occlusion, but I’m giving you something that’s really, really prized. I was actually going to save this one for another time in the future, because we’ve got Jorge Cardoso, from Portugal, who if you remember from Episode 49, I think it was crystal clear treatment plan letter. So if you’re looking about presenting your treatment plans in a letter, which is going to be very compelling, concise, easy to understand for your patients, then I will definitely listen to that episode. And check out makemeclear.com and use the protrusive 25% discount code because he’s been very kind to give that but today is all about vertical preparations. What are they revisiting something that we also tackled in Episode 19. Go look at me referencing all these episodes. I have enough now to reference in the past. Check that out anyway. So Jason Smithson came on episode 19. We talked about verti perhaps and Emaxs, onlays absolute cracker of an episode, even though his audio wasn’t that great. It was so so jam packed informative. Now we’re taking that verti preps. And we’re going a little bit further with Jorge Cardoso today. So we do revise like what is a vertical preparation of crown? How does it differ to a traditional crown preparation using a shamfer or shoulder? What are the considerations for anterior and posterior vertical preparations, but also then delving deeper into how we can we move away from traditional impressions and analog? And can we actually employ digital dentistry when it comes to vertical preparation? Something that’s not spoken about very much, actually. So I’m hoping you’ll find this extremely valuable. So the reason I was gonna delay this episode is because when me and Jorge are talking, we actually figured that actually a lot of people want to learn more about vertical preparations. A lot of people, a lot of dentists want to learn how to use this technique and they want to go in a hands on course now, I’ve been on Jason Smithson’s course, if you’re in the UK, and you’re looking for a really good course, on vertical preparation, Jason’s is the one to go. I enjoyed it very much last year, and it’s very much had a big influence on me as well as people like Pasquale Venuti. Who also taught me a lot about vertical preparations and the Tomorrow Tooth facebook group. But now me and Jorge are talking about an excursion to Portugal, because some of my best memories as a dentist have come from taking educational courses abroad, be it you know, Sweden, Europe or on a ski holiday, which also doubles up as a CPD sort of dentals over educational events. So these holidays are often the most memorable. So we enjoy your thinking maybe next year if you guys are interested to learn about vertical preparation hands on, but also have a little holiday at the same time tax deductible. Then why don’t you sign up on protrusive.co.uk/vertical-portugal. That’s /vertical-portugal. Now if you put your email address in there, when and if this happens, I’ll email saying you know what we’re kind of thinking we’re gonna get 15 to 20 dentists, Protruserati to go to Portugal together. No matter where you’re from in Europe or the world even to go to Jorge’s clinic and he’ll teach us hands on vertical preparations. So we can delve further into this technique. So bear that website in mind. I’ll put it on the YouTube or on Dentinal Tubules or on the main page @protrusive.co.uk. That’s it. Like I said, another reason why I was delaying this episode. But now that I can’t give you the basics to occlusion, I’m giving you this one about going digital when it comes to vertical preparations, and revising all about from a different angle, a different perspective, from how much cement space you need to making sure that you don’t get undercuts, in any form because they can be very detrimental. Me and Jorge share some failures that we’ve had using verti preparations and how we now realize actually, we did something wrong. So learn from our mistakes. The Protrusive Dental Pearl I have for you is regarding impressions versus digital. And really, the main message I want to give you is, if you are digital, or if you’re going digital, remember that you need to be more aggressive in your tissue retraction compared to impressions. Let me explain why. Imagine you have a sort of equigingival or slightly subgingival crown preparation, and you’re going to be taking impressions, that light bodied silicon material, for example, is thin enough, they can creep into the sulcus space and capture that area. Whereas with digital, if the light cannot get there, it will not record it. Therefore, in those cases where I think I’m going to get away without using code here, with impressions, I’ll be fine. But if I’m thinking, if I’m unsure with digital, you better bet I’m gonna place a cord. Okay. Now with impressions, when I can get away with just one cord, then I know that I’m going to be doing two cord techniques to get that vertical and horizontal retraction of the tissue. So everything that I do with impression, I take it one step further when it comes to digital scans, because you need to be more aggressive with your tissue retraction, need to show the scanner more. It can’t creep and flow like our impression materials. So just remember that little tip. So let’s get down to the main episode and I’ll catch you in the outro.

Main Interview:

[Jaz]
But you’re now been on the podcast before, Jorge, it’s great to have you on again. If anyone hasn’t checked out the episode, we talked about Crystal Clear Treatment plans with Dr. Jorge Cardoso with makemeclear. You need to check it out that has actually impacted so many dentists because they came away having a clear idea of how to communicate better with their patients, both in terms of verbal and of course written. So please do check out that episode. I will link it in the show notes. Jorge, welcome back again. How are you?

[Jorge]
I’m fine. Thank you so much for having me. It’s always a pleasure to be talking to you. And thanks so much.

[Jaz]
I’m glad to be discussing today something like obviously, we talked about communication before. And we talked about written Treatment plans, which is so important and something we don’t talk about enough. But you’re such a talented dentist, Jorge that it’d be a real shame if we didn’t do a clinical episode. And like, but you’re the only dentists who are so just brilliant at everything. And I think what kind of topic can I give, so we can niche down in something. And I love how much of the vertical protocols that you have adopted. And I love how much you’re pushing the boundaries with digital. So this episode is more about vertical preparations specifically in terms of digital verti preps. So let’s just dive right in. For those people listening who still have no idea even though I covered a little bit with Jason Smithson in one episode is a little bit rushed, because we did half on Emaxs onlays, which could easily be a five hour episode and half of verti prep, which could be many episodes as well. So in your view of the world, Jorge, what is a vertical preparation? Because some dentists be like, I have no idea what this is.

[Jorge]
Okay, so the vertical preparation was something that actually changed completely, changed the way I approach initially only posterior teeth. And now, as for me, every time that I go for a crown, that I’m doing something which is non adhesive, every time that I go for resistance and retention, the vertical preparation is by far the best approach that I can go. So I completely changed my practice completely changed my practice. Initially, I have to say I was a little bit skeptical because I thought maybe it’s too thin, it will break or maybe the technician will not see the finishing line. There are so many things that we have inside our mind specially when it goes for fixed prostho which actually when you really think about it, and we look into literature, about 30 to 40 years ago, we already knew that vertical preparations were actually very good. So just a little bit of historical perspective. So when the PFM started, it was about vertical preparations for the finishing line was metal. So then we evolved a little bit and we wanted to do what it’s called the ceramic shoulder. So we wanted to have more space for the dental technician to layer down the ceramic. So instead of being like a feather edge margin, we started to get horizontally, a shoulder or chamfer. So that would give space for the dental technician to hide the metal on the cervical area and to provide better aesthetics and we kept like that for 20 years. But then something interesting came up which was CAD CAM right? And because of CAD CAM what happened is that we wanted to also to have a very thick amount of material in the shoulder area. Right? So instead of being minimally invasive what CAD CAM brought I don’t know if you remember the Procera crowns from Nobel Biocare which were the first all ceramic alternative to PFM And what happened is that we became even more invasive. Why? Because CAD CAM leaders wanted to have space right? So when we started to have CAD CAM, vertical preparations seemed even far away because we never thought that CAD CAM machines would be able to mill such thing, margins. So more recently and Jason Smithson and get some tomorrow tooth group and ripe group, we really start to look a lot into vertical preparation and I was curious as I started to follow them. And I in the beginning, I was a little bit skeptical, but then study start to come out to say that A) Zirconia feather edge margins behave as well as shoulder ones. So in terms of literature, in terms of safety, we are safe to go. Now the main advantages, you are saving more teeth, you are making your life easier, your impressions are easier, the fitting is easier, and something which really attracts me periodontal stability is much, much higher. So you can’t lose with vertical preparations.

[Jaz]
I 100% agree with you and the most common I wouldn’t say objection. But the common question I get is, everytime I posts on social media about vertical preparation, which I completely have the same reservations and revelations as you Jorge because initially, the first thing you think is weight, biological width concerns, how thin the material is, all these concerns that we have. And it’s just such a paradigm shift from being trained at dental school to create this clear, you know, shoulder one millimeter plus that the technician can see. So to having no shoulder and being featheredge is such a massive shift that initially it felt like I think [Mascheroni] called the vertie prep, the dirty prep. So there was a lot of resistance amongst the sulcus for the right reasons, I think. But I think once you truly understand the biology of healing, what we’re trying to achieve, and for me, the main reason now I have also switched to when I’m doing something non adhesive, ie when I have a preparation that does not have enough enamel, that I do think the most minimally invasive technique is a vertical preparation because the preservation of the Pericervical dentin and like to make it even more tangible, like you gave a lovely historical perspective is, let’s think about like nowadays, imagine you have someone with lots of recession, because of periodontal disease, and you have such a long crown height of a lower premolar. Right? If you cut a shoulder into that tooth, like you’re going to be at the root, you’re going to be into the pulp into the root filling whatever it just doesn’t make sense. So you want to something knife edge, but the way that this is a BOPT with especially with the works of Ignacio loi, which again his paper I will put on the show notes as well, great landmark paper that showing that okay, what can be achieved in the aesthetic zone, it was brilliant. And not only is it can be minimally invasive, but you can really get an aesthetic results. Like I have some cases I know you have as well, where we prepare for vertical. And then the gingival zenith will migrate and you actually are growing gingiva. And when you can do that. You that’s a cool moment. So why don’t we, Why don’t I pitch it to you, Jorge about what about those dentists that say, “Hey, by going so subgingival with the prep, are you not encroaching the biological width? Can you bust that myth for us?

[Jorge]
Well, the thing is that initially, I think that was the biggest barrier for me to devote to preparation, but then I realized exactly what is a vertical preparation. Well, I don’t want to make it very complicated. But there are basically two types of vertical preparations. That’s the BOPT type, which is basically edgeless preparation, something that you go, you prepare right into the bone. So the BOPT from Ignazio Loi is like evolution of the first words from Di Febo and M Amsterdam. So basically, it’s a periodontal preparation, very aggressive, okay? So that serves the purpose of going very deep, cleaning all the bacteria and also let’s say resetting the periodontal tissues, okay? So that is a very invasive preparation, and that should be reserved, that should be reserved for cases that need to do so like periodontal case or stuff like that. Okay. But then there’s another type of preparation, which is almost more known as the verti prep, which is basically a preparation that does not go as deep. And one of the main differences of this preparation is that you can actually do the impression on the same way, okay? So if you go very deep, you should not do the impression the same day, you should let everything heal. But if you go not as deep you can actually make the impressions on the same day. And usually when I look don’t go as deep I leave that to cases of posterior restorations, okay? So the BOPT what I usually do is I do adaptation and I do something like so let’s imagine the BOPT, one thing or one of the good things about the BOPT is that you can actually play around with the levels of the gingiva Okay? So you it’s a more invasive preparation, which on the anterior cases, you may say well, why are you being so invasive on anterior cases you have to remember one thing. So, the vertical preparations which are divided into like BOPT and verti prep, two different scenarios. The vertical preparations are preparations that are a type of crown, they are not an alternative to the veneer, they are not an alternative to the onlay. So, you have decided to go with dentures, you have decided not to go adhesive, then you choose a vertical preparation, okay? So in the anterior region, when we are thinking about vertical preparations is because I already have almost no enamel and darken substrate. So if I want to use a vertical preparations, I would need to be very aggressive on here, you want special on the buccal part because I want to have space to do like a ceramic shoulder like artificial new cementoenamel junction. So I go very well. For posterior cases, what I do is I do same day impression and I usually stay all in the sulcus, okay? So for the posterior, there’s no problem of impinging the biological width. Now for anterior, you see, you are going very deep with the first preparation, yes, but I never do the impression on the same day. And I always need to let the tissues heal only after they heal, then I do the regular impression. So I always stay inside the sulcus, even if I go very deep on the first impression, because I like to and I think that’s beside the sulcus. And then on the posterior one, even if I do the same day impressions, I always stay on the sulcus. So those are two different approaches.

[Jaz]
With the anterior one, perhaps when you’re going much deeper almost to the bone, and you’re getting that “Gingitage”, the removal of that inflamed gingiva, and then as it heals, it will form this new sort of junction epithelium. How are you temporizing that to get the sort of advantage of the biology, ie you are dictating where the gingiva zenith will go by using your temporary in a clever way. So any guidelines as to how far to extend your temporary away from the base of the sulcus?

[Jorge]
So basically, when you do a preparation, you are actually very deep and there’s bleeding. So even if you want to go really deep, you’ll never be able to reach very deep with your temporary. So I would advise you to say like, Okay, this would be because we are talking about aesthetics, I want to leave the margin where the adjacent tooth is or where I wanted to be, okay? Then I let it heal. And then I readjust, I can go move up, and I could move down. But basically, it’s a aesthetically driven, the placement of the margins is aesthetically driven. Now you may say okay, but you are probably if you want to go very deep, if you want, let’s say you want to increase the margin do like a crown lengthening, in my opinion, I will do the crown lengthening before that. So I will not, I will stay away for biological width invasion, always, I will always stay away from that.

[Jaz]
And just for the young dentists, you know, learning about this, for the first time, how many millimeters, classically are you trying to form from the alveolar crest, the bone to your prosthetic margin of the restoration. So you’re saying that if you have to go so deep that you actually want to do crown lengthening, then you will actually do the crown land thing first before you do the BOPT approach. But how many millimeters are you aiming for?

[Jorge]
Okay, so but what you want to have your margin should be maximum two millimeters close to the bone, that’s the maximum. Okay? So you should not go with your margin like one millimeter close to the bone because that way you can have unpredictable results. You can have either inflammation, you can have either recession. So you want to stay deep in the sulcus. So let’s imagine from the bone up to the gingival margin. You have connective tissue, bone connective tissue, one millimeter average, generally one millimeter. So those two millimeters are the biological width, you don’t want to mess with it, okay? You want to stay away from that. So when you are doing the crown length, and you have to imagine that your final gingival margin will be three millimeters from the bone and you will be inside the sulcus one millimeter. So the final gingival margin three millimeters, your prosthetic margin, two millimeters inside the sulcus. Those are the limits you should not go, you should not mess more around with that. Now, one thing is important, I talked about two options, BOPT for anteriors when you have more control, and you are more aggressive for an aesthetic concern, especially on the buccal. And the thing is, this is very important, what makes, we don’t know exactly why the result so well in terms of periodontics, but the fit is better because the cementation gap will be better. And also very important you are always thinking about the biological width the vertical way, right? It’s three millimeters. But there’s the horizontal component of the biological width this is very important. I cannot tell you the definition but I can give you a couple of examples to make light in your head, which is, you know, when you have for example, a cross lateral incisor, so it’s crossbite, everything is okay in the occlusion lateral incisor’s crossed, always that gingival margin compared to the other tooth.

[Jaz]
It’s gonna be thicker on buccal, usually, right?

[Jorge]
Why is that? Because there’s a thick bone, because there’s a thick bone and this is really important, the bone is thicker horizontally. So the wall the needs more space vertical. Does this makes sense? So this is one option. The other option is this, so look at orthodontic movement, you place a tooth more towards the palate, gingiva grows, you place the tooth more towards the buccal gingiva recedes. So the thicker the bone, the more space the body needs to get. Because usually we’re talking about three millimeters to biological width in one sulcus. But if the bone is too thick, horizontally or vertically, you may be three or four millimeters. And going back to the lateral incisor for example, if you go there with electric scalpel, you just get the gingiva, but what will happen? It will grow again, because the bone is very thick there. Okay? Now let’s imagine we can do this prosthetically, I go to the buccal area to the root, I reduce it. So when I reduce the root, I’m increasing the thickness of the bone. So the bone, the body will naturally try to create more gingiva because they need more space. Basically, you are fooling the biological system and telling it Look, you have a very thick bone. And because of that you need more vertical space. So the tendency will be number one sometimes to grow, or at least and this is very important. Number one to grow in vertical preparations, or at least not to receive as much which is a big issue that we have with horizontal preparations. And let’s be honest, I usually say these all the on social media, there is no recessions on crowns. No worries.

[Jaz]
Absolutely. I mean so many times. In the past, I’ve done crowns or the horizontal margin, and everything that perhaps looking good when I come to fit it, there’s already been some recession. You know, one millimeter is not much but it’s a shame because you remember prepping equigingival or slightly subgingival about this and recession that’s happened. But with the vertical, like even if I’m doing PFM, and I’m having a metal color, going subgingivally, when they come back in the future, the gingiva has migrated and grown and I can actually get the flat plastic moving away. And I can see that metal color tucked in beautifully subgingivally, which is another reason why again, I have also, like you, move to vertical. So because I think in the interest of time you want to cover the digital aspects of all this. So let me just get open this up now for the questions I want to ask you. What is the difference in and you might have to describe this is in your traditional protocol when you were starting off with impressions, and it told me about the cord you might place at the beginning like some dentists, they put in ptfe first, then they prep and they keep that and they prep to the ptfe and they scan with the ptfe in, And is that also what you would do in when you were doing impressions? Or is that only now with digital? And how is your protocol different now that you’re doing more and more like myself digital vertical preparations or vertical impressions?

[Jorge]
Okay, so the first thing that you have to understand is that impressions are much more predictable in vertical preparations and horizontal. Why is this? Because if let’s look at traditional impressions with silicon, let’s do an, let’s think about the horizontal impression. Where will the air bubble end? In the worst place, in the margin. It always ends there. Always. If you think about vertical impression, because there’s pressure from the putty, where will the bubble go? Into the sulcus, where it’s not relevant. So it will not even if you have a bubble in the sulcus in the deep part it will not have a problem for another technician while if you have a bubble on the horizontal preparation it always stays on the margin and on the worst place possible. Okay, so traditional impressions are much more predictable in vertical preparations and I will do them exactly the same way as I will do horizontal preparations, it depends on the technique, sometimes you prefer to do double impression, sometimes you prefer to triple impression, but they are, they will always be more predictable, always I can guarantee that to you. Now, the silicon goes deep there. Now, with the vertical impressions, I think that they are more challenging than horizontal impressions with digital scanning. Why? Because there’s this they are deeper, and then the gingiva has the tendency even sometimes when you use double cord, the gingiva has a tendency to do this, to go and hide and create a shadow deep there. So number one, something that if you want to go, I always say this, if you want to do fixed prostho, you need to have an electric scalpel, or you need to have some top notch periodontal patients without any sort of inflammation, which is almost impossible. So I would advise anyone to do prosthetic, fixed prosthodontics to go, you have an electro surgery scalpel. Because this is really critical. This will allow you to do sometimes when the patient is not the better sometimes there’s a little bit of inflammation, you can just go there and cut the thickness of the gingiva. I will not cut it horizontally, I will not cut it vertically. Let’s say I will only cut inside the sulcus so you have correct space for the scanner to mill. Now, if you have a heal site, so the site is healed, the site is healed. So you do the preparation and you go for the second appointment for the scan, which is something that I rarely do. If you do that you can do double cord technique because the tissues are healed, double cord and if there is any area there that still making a shadow just go with electric scalpel and cut it there. Okay? This is number one, electric scalpel. Number two, the best way to control bleeding is, in my opinion, the retraction paste from 3M. 3M retraction paste, it’s a miracle, an absolute miracle. First situation is healed you do double cord and you’ll be fine if you want you can use like electric scalpel just remove the gingiva eventually recovering. That’s number, so double cord and you remove the outer cord before the impression, one of the good things about digital impressions is that if there is some area that you see is not good, you can go there, erase it and redo it, which is something absolutely amazing. I think that you will agree with me about that, right? Yeah, that’s perfect. Now second situation, which is what I do, I usually try to do preps for being more productive, I took the of the prep in the same day of the impression. And here we have some gingival challenges in terms of healing of gingiva and stuff like that, then we are always dealing with bleeding venture. So in those cases, my protocol is usually so I do the prep. Okay? I do the prep. I do the electric scalpel just to do some, to stop the bleeding. And additionally, I use the paste from 3M, retraction paste, which is absolutely amazing. So many people are familiar with Expasyl Paste, I think this one works better. This one is much more ergonomic in terms of the application. So it’s something that you really should have. So two things important to have electric scalpel and 3M retraction paste, so I cannot live without that.

[Jaz]
So at this time of prep, there’s no cord in already, there’s no ptfe in the sulcus already for you, in your in your way?

[Jorge]
Yeah, preparation, electric scalpel, retraction paste. And for this situation, what I usually prefer now is to do Teflon. Okay? So the thing about the Teflon, there’s like a small learning curve, what the way that you apply the Teflon is not the same way that you apply the cord. So on the Teflon, you have to do some pressure and keep it there for about two seconds and remove it. Pressure, keep it there for about two seconds and then remove it. And what happens that the Teflon will actually spread the way the gingiva and you will actually see people spread away the junction epithelium, okay? It will slightly spread away the junction epithelium. But then the good thing about the Teflon is that if you use a colored scanner, what I usually asked my dental technicians that go all the way until see the white, that’s when you stop your finishing line and you will not have any issues and it will not be impinging the biological width. Okay? So this is usually my strategy. The third case is extreme cases. One thing that I really love about vertical dimensions and we talked about BOPT technique, vertical preparation on extreme cases. What do I do? I do a mix of both of the techniques. What are extreme cases? Cases that are being considered for implant. So, remember one thing between the gingival margin and the bone we have three millimeters, sometimes you will always gain, find ferrule that you are not finding above the gingiva, but you will be able to find ferrule below the gingiva, right?

[Jaz]
Another massive advantage of vertical. Absolutely.

[Jorge]
Now, here comes the criticism. Okay now, if you go below the gingiva, now, you are at risk of going into the biological width and it is true. So, what I do is this, extreme case preparation, BOPT preparation up until the bone because I want to maximize the amount of [transparency] then what I do I do electric scalpel okay? just to remove the hemorrhage and then retraction paste that then remember we have no sulcus here, you cannot place anything because what you are seeing is the bone. So, what do I do? Direct scanner. I know this is a little bit outrageous, but then comes the trick I tell my dental technician exactly where to place the margin. Where do I place it? At least one millimeter away from the bone, but then you’ll ask, well but then you will be in the junction epithelium, so, you are impinging the biological width for one millimeter? It is true yes I am impinging but I’m waiting the pros and cons, I am saving a tooth with a risk of causing some gingival inflammation. But on the other hand, I am saving a tooth, which is for me the most important thing. Now you can ask me why won’t you do crown lengthening? I stopped doing crown lengthening on posterior teeth for two reasons. If you do it in proximally, you will lose the papilla and even with good contact points there will be full infection. Buccally or lingually, remove the bone you are compromising your future implant and you may eventually forcing vertical augmentation or sinus lift. So what now what does the literature or the research says in terms of the biological width?It says two things First, we don’t know exactly. It’s not predictable what happens in some cases you invade biological width and what happens there is a chronic inflammation that is never go away. Sometimes there’s a small inflammation for one or two months until the bone is sourced to make, to create the new biological width, okay? and some other situations, nothing happens as long as you stay like one millimeter away from the bone. So we don’t know exactly what happens. And for example, the last classification of periodontal disease, they say, you should not go in the connective tissue, which is very close to the bone. But we don’t know exactly if it’s safe or not to go to the junction epithelium. And what I do, I go into the junctional epithelium and I assume that risk per To be honest, I never had any issue, but I assume that risk of invading one millimeter of the biological width, the junction epithelium, but I will never go to invade the connective tissue very close to the bone. But remember, I am only doing these in extreme cases in good periodontal patients and also in cases where the implant is being considered. So I am taking risks in extreme cases. And in that case, I only use the preparation, expose the bone, electrosurgery, reduction paste, and then I will not use anything but I always tell the technician stay away from the deep of the sulcus because what you are seeing is the bone, stay away one millimeter. And because you have no sulcus because you cannot place anything there. Okay? I don’t know if this makes sense.

[Jaz]
It make sense. And I think it’s a good description of the indications of that extreme approach. So that all makes sense. You were trying to save a hopeless tooth, but also preserve some bone for the future implant and preserve the papilla. So that makes perfect sense. And I like that. I think I’ve learned something from that for sure as well. In terms of I mean, you’re obviously scanning in those preparations. And you’re telling the technician to just stay at one millimeter away from the bone, which is awesome. And as long as you use the electrosurgery, you can actually create that vision, create that path of scanning, or the ability for the light to reach there, that’s the most important thing the lights will be able to reach there unimpeded. So it can record that area. So that’s very good. I’m just going rolling back a bit to those BOPT anterior cases that you might be doing well, you’re being quite aggressive because you want to change the gingival level. Are you scanning for that as well? Or are you taking impressions for anteriorly? Because me, if I’m having any anterior cases, which mostly I do more posterior cases, I’m happy to scan. But for anterior, I have my biases still. Because I don’t have as much faith in scanning. I will really want to try and do the BOPT go quite subgingival, I’m still taking impressions. So what would you advise me in that regard?

[Jorge]
For the anterior cases, I do either way, if it’s like a small cases like one or two teeth, we go for scan without any issues. If it’s like a bigger case six or four I usually go for the traditional scanning but that is just a question of you know that the higher amounts of teeth, the more areas are eventually placing on the scan that’s just because of the technology but I if the technology evolves in the future, I would actually do the scanning without any issues. I don’t know if I can show you an image here because I think it will make

[Jaz]
and while you’re finding this if you don’t mind I’ll ask you a question while you’re finding this. So for those people who reminder these podcasts are not just audio only I know many of you drive or listen to the podcasts but these are accessible on YouTube, on Instagram on downtown tubules and a few more platforms coming soon as well. So if anything any my guests like Jorge is going to share something now you can check it out in the video part as well. I love this fantastic. So it’s definitely worth I can see the graphics already, which is good. But this whole concept Jorge of kissing the bone, I’ve seen some on social media, we like that term, okay, this preparation now, or the crown is kissing the bone. And because your crown, your metal ceramic or the Zirconia is so thin. And that it’s like it’s been it’s almost like 0.3, but then it gets tapered down to you know, infinity and such a thin smooth color that some people say that actually, the biological width is less of an issue because everything is so smooth. What’s your thought on that?

[Jorge]
Well, to be perfectly honest, we don’t know exactly all the reasons why they work so well. We have an idea and I think that because it’s very thin there, the adaptation is better, we know since the 80s and this is really interesting. We know since the 80s, that the other patient have vertical preparations with an adequate design of the cement with an adequate design of the cement, we know that the fit is better than horizontal preparation. So if the fit is better, if there is less of a gap, of course that the periodontal tissues will like it more, that’s number one. But number two and I cannot stop emphasizing this, you notice Do you know here the aggressiveness of this preparation? So this is the horizontal one. You can see my arrow right? This is the horizontal one

[Jaz]
Okay, the error I see is that between the bone and the connective tissue, there is no attachment right.

[Jorge]
So on the left side, what you have is an horizontal preparation, right? It stays in the sulcus. On the right side you also have horizontal preparation. And because I have, this is a BOPT technique because I like to it’s also on the sulcus, because if you let the gingiva heal, if you do like level of cord, you will never go deeper than the sulcus because unless you are very aggressive of course, but the big thing here notice the amount of aggressiveness in terms of buccal preparation on the right side, you see that? So what happens is that the periodontal tissues they get thick and because they get thick, they want to grow or at least they do not receive as simple as in case of a thinner bio type. So, basically, what you are doing is you are actually boosting the biotype because you are increasing the thickness of the gingiva not by increasing the gingiva itself, but by reducing the buccal root and when you reduce the buccal root, the gingiva wants to grow Always remember that the orthodontic movement, if it goes buccal the gingva goes away, if it goes palatal the gingiva wants to grow. So, what you are doing is like prosthetically creating that same environment. So the gingiva wants to stay there, she does not want to receive and that is because of the aggressiveness of the preparation. And what you are seeing on the right side is that you are creating a prosthetic new cementoenamel junction, you are creating a new cementoenamel junction. And you may say well, Won’t there be any food impaction? No, this works. My experience this works much, much better than any other sort of horizontal preparation. So I think that the periodontal thing is the issue really

[Jaz]
Amazing. And I think for those who are listening and maybe not watching this, the best analogy I can give when I was studying orthodontics is my old mentor, Mohammed Almuzian he says that the gum is like a skirt. Okay? So if you bring the tooth or in this case, the vertical crown forward, the skirt lift. So it’s like bringing your leg forward, right the skirt is going up. Okay? If you bring the vertical crown down or further into the tooth, the skirt, the leg is coming down, the skirt is coming down. So if you’re struggling with that analogy, think of it like a skirt and how you lifting up the leg, lifting down the leg and how the gingiva will migrate like the skirt, which is something else that you reminded me of, as you were showing that.

[Jorge]
It said it’s the same thing as with implants. So Critical Control and Critical Control is exactly the same thing. It’s the same thing. The analogy that you use is the perfect analogy for the vertical preparation and so answering your questions, two reasons why they work so well periodontally, the fit is better and if you use the BOPT technique, especially the BOPT technique, when you are a little bit more aggressive on the aesthetic area, you will increase the thickness of the gingiva and the gingiva wants to grow. Those are the two main reasons why you will get so much many good results. And there is no recession almost at least in my cases, I’ve been doing vertical preparations for about three to four years. And honestly, I’ve never seen such good, healthy periodontal tissue and stay on the long term,

[Jaz]
I can definitely echo the same. I’ve also been doing it for three years and I can echo the same. And it’s something that’s very definitely revolutionized, my practice, I know it has for you as well. And it’s great to be able to have that option for our patients. Now one thing that you I picked up on when you were speaking is about the correct spacer protocols. Can you just elaborate on how much of the spacer you are advising your technician to use obviously, with all my CAD CAM here, what is the digital amount of spacer in microns that you are suggesting to your technician?

[Jorge]
I will show you a slide which is very important for you to see.

[Jaz]
Amazing. Now, whilst you’re doing that, I’ll just share some of my challenges. When I initially started with vertical preparation, I didn’t know what I was doing. I had these crowns back, and they were so tight, I couldn’t seat them fully. So I don’t know if that happened to you earlier on as well. And then I learn online from my mentors that actually is because of the fact that the walls are so straight and so deep that if you need more spacer, you need more space for your cement, so I’d love to hear your current protocols.

[Jorge]
When you do not give the right amount of space, you see this clinical case with a fracture here on the cervical area? So you see the cervical fracture here. That is because of incorrect. So why was that? Because in the beginning, I had no notion about these. Now, if you talk to most dental technicians, they will tell you that the cement space, the traditional cement space is something like this. Okay? So this is very important. So the first millimeter from the margin is 0 micron. Okay? So they want full adaptation. Okay? And then from the inside, as you see here, they place 40 microns. So what is the issue here? And we know it’s interesting, because I’m writing an article about this. And we know this since the 80s. There are studies in the 80s that show that when you cement this, there’s the flow ability of cement to the occlusal area, and you will never get the perfect fit here. That’s number one. And worse, no fit, no complete fit and without cement because the cement will go upward. So you have an open margin. And they classically say you can have an open margin of about 120 microns. So that’s what classically it’s accepted. Now, for vertical preparations, you have to do the opposite and this is very important. So the occlusal area should be 0 micron. So when you are placing the crown it should, the stop should be on the occlusal area. And then you should open the margin 40 microns. Why 40 microns? Because this is the average thickness of the cement. So with the vertical preparation, you will not only have a better fit because the crown will go all the way. But also you will have cement in the margins, there will be almost no. And this is something that I when I was writing the article I said well, this is just something that someone said on social media. So I went to search in this literature. We know this, Jaz, since the 80s. We know this works this way since the 80s. And it’s amazing why we keep doing the opposite. We keep doing zero at the margin of the cement design And then we opening inside. Why we should be actually doing the opposite, which is zero on the occlusal and then opening all the way up until the margins? Because if you do the classical approach on vertical preparations, you will have fractured like I showed you. And I hope this clarifies it. Does this makes sense to you? Yeah?

[Jaz]
It makes perfect now. It makes perfect sense to me because I’ve been in this journey. I’ve had the failures myself. And I realized that actually things are just too tight at the base as a seating. And then I started playing around my spacer protocols I learned from people like Pasquale Venuti I know you’re lecturing with him soon in Portugal, it’s such a great conference you can tell us about that very soon. So I wish I was there to go on to do because I’m a bit of a vertical geek now because of you guys. But yeah, so I learned this the hard way but recently more than I had an issue where I will as I was seating the crown, the cervical of Zirconia fractured, quite heartbreakingly and I can’t figure out exactly why, and may be a to speak my lab again, did they follow the spacer protocol correctly, but I actually think I had an undercut area there and I think that was my own fault.

[Jorge]
Exactly. That’s also something very important. Let me share the screen again, because I was showing the images of common mistakes. Another common mistake is, so we talked about the cement space, which is critical. There’s another issue, which is, if you go with the same mindset for the vertical preparation, as you will do for your horizontal, you will always create undercuts, and this is really important. Why? Because when you do undercut, you see here, this is the scheme of when you do an undercut with a horizontal preparation, that technician has the space to cause an alleviation. They will call like, relief in this area. I don’t know if this is the correct term to say,

[Jaz]
Yes, they blocking out, they block out the undercuts, if you if you make an undercut in a horizontal crown, they will block out the undercuts, yeah.

[Jorge]
But if you make and then they’ll go to the vertical, will they be able to get it? To block it? They won’t, they won’t. So in the first, during the first two years, I had a lot of undercuts, the dental technician will call me Look, there’s an undercut, look, there’s an undercut look. There’s like why because you go with the same mindset, with the same visual hand approach. So you have to make sure that when you do the final image, you see, because if I was really paying attention, you can see here, there was an undercut in the buccal area. It’s clear.

[Jaz]
This is such a good image, Jorge, just wanna highlight that this image that you showing I mean, for anyone who’s listening, you need to go back to this episode and watch this because what Jorge is highlighting here is looking at the tooth, like, you know how you check for a path of insertion for crown like for horizontal, he’s highlight an area where he cannot see the sulcus, and that’s where the undercut is. Am I right in describing that?

[Jorge]
Absolutely, Jaz. And what are the consequences? I say, Well, I just didn’t see that. I’ll say, well, just do it anyway. Right? Because the patient she’s okay with, just do it anyway, so they did it, look what happens. It did not go all the way because it was not possible to go all the away.

[Jaz]
So I mean, I tend to make my vertical preparations a little bit more tapered for that reason, and sometimes I’ve been a bit guilty of over tapering. But I think this is a kind of a necessity, I just need a bit more handpiece control to make sure it’s really easy. It’s really easy to lean in and over taper it right?

[Jorge]
Absolutely. Look, I think that I came into this journey, I did a lot of retentions then I started to excessive taper. And now I am almost getting the right one. But my opinion, if you want to do vertical preparations stay on the safe side and do a little bit of more excessive taper. Also, because the retention of the crown will be so good. I usually use a self adhesive cement and self adhesive cement does not mean true adhesion just like RelyX™ Unicem or Maxcem but you can also use some FujiCEM reinforced glass ionomer, you can use whatever you want. But even if you do a bit of excessive taper that will not be a problem because the retention of the vertical crown is very, very, very, very good. So I usually I do a lot of retentions not then I went through a phase of excessive taper which I still do I have heavy hands, my brain is much more better than my hand. But I don’t have an issue. So in doubt, do more taper that will make you better for you, for dental technician and in my opinion also for the patient. And remember one thing when you are doing vertical impressions is not because you are doing an alternative to blocked because I think there’s a bit of confusion here. So people said Well, I stopped doing onlays I only do vertical preps don’t do that because you will be doing excessive tissue preparation. So what you have to do, you have to look at the cases and look, this is the case for a crown okay. So instead of doing horizontal, I will be only vertically. So if you if you do select the cases that you need to do, you will be on the safe side. In my opinion, excessive taper is always better than limitation.

[Jaz]
Amazing that is sensational. I think that’s going to help a lot of people. So all those mistakes mean you have made a Jorge if you listen to this episode and learn from our mistakes, you will be doing the correct taper. The correct spacer protocols, the correct way of scanning or taking impressions, make sure you can see the sulcus, there’s so gems that we’ve shared. So that is amazing. you’ve answered all my question. Just one more thing do you think or do you think there’s an inadequate scanner out there? Or are they all reasonably okay to scan for vertical preparations?

[Jorge]
So my advice if you are considering a scanner, of course you have to you have to see if it fits for you financially, but I use the Medit i500 now there’s a new one the Medit i700 and in my opinion, it’s the best value for money. It’s the best value for money the i500. Now the issue is if you are working in a place where they are doing Invisalign, you cannot use the Medit because they are not allowed to use Invisalign. So I will probably go with the itero or with a 3shape, something that accepts Invisalign, if you want to ask me what’s top notch, money is not a problem, then you go for Prime scan from Sirona, but money value for money for myself, the i500, from Medit, and the new, the i700. They are amazing, the updates are amazing. And there’s a very good support group on Facebook and the the team, the development team is very, very good. And we are you are getting a price scanner for like 50% or 60% off the price of the most well known scan, which are the 3shape and the itero. That so what is the consequence of that my orthodontist that does Invisalign in my practice cannot use the scanner, she must do manual impression. So that’s the issue.

[Jaz]
Yeah, I’ve seen a big, you know, hoo-ha on social media about the merits of the i500. And now the i700. I think a lot of associates are buying their own scanner because it is much more affordable. And that’s great to see. But you’re right, I think the caveat is Invisalign, but more a lot of clinics now they have multiple scanners, they have one itero for the Invisalign, and then they have the Medit for estorative and that’s okay, you know, depends on what works in your practice and the budget. you’ve answered all my questions, Jorge, you’ve been absolutely amazing with value. Honestly, I can listen to you over and over again, but just due to time, we’ll have to call it there. Please tell us about the projects the teaching, anything that you have on vertical preps. I know you got The Brain and Hands. Tell us about The Brain and Hands. This is your moment to just, How can we learn more from you because honestly, I know the listeners, the Protruserati, love your style.

[Jorge]
Well basically I am a nerd. I’m a dental nerd. I love to do publications. I love to teach. I create The Brain and Hands, the website which is very good if you want to, if you have any doubt in terms of cementation protocols or vision protocols there’s a step by step it’s all free. I also share some videos with with some tips. I do lots of courses here in Portugal and this vertical preparation courses because we join forces with Venuti, with Hugo Costa Lapa, with Raul, with Miguel and they did the verti prep. The verdi prep course in Lisbon two years ago, it was an English highly successful event I was there I learned a lot from them. And then I started writing an article which I really hope it comes out this year. Next one, which is basically so let me give you this in first and it’s called CARES concept. It’s called clinical decisions for posterior restorations Part One: Partial Adhesive. Part two: Full resistive or retentive crowns and the CARES concept is this you have to think about Coverage-C, A-Adhesion, R-Retention or resistance, E-Esthetics and S-Subgingival management. If you think about all these concepts, you will be able to do a treatment plan, good diagnosing and a good plan for doing single unit posterior teeth. So I hope that the article comes out this year. So to basically answer all the all the questions I hope, of how you should diagnose, plan and execute single unit posterior teeth, either if you are talking about adhesive, tabletops, onlays, overlays. Or if you’re talking about retentive resistance, which is the vertical preparation in this case and on the 10 I think it’s the 11th and the 12th of June this year, because we cannot be doing we could not be able to do it because of the pandemic but this year because of travel limitations, this evasion will be in Portuguese in June. So it’s only for Portuguese because all the other foreigners they have travel limitations. But I am pretty sure that eventually this year next year we will be doing the same edition in English and I hope that you come over to Lisbon to visit us.

[Jaz]
I would love that choice. And what I’ll do is if I speak to the Protruserati, who I know they want to learn a vertical and we also have been meaning to do a little getaway. Right? So if I can organize a group of the Protruserati, right? To come and fly as a group. It’ll be so much fun as a group we all fly to you. We come and look at your practice. You teach us vertical preparations. I think that’ll be amazing.

[Jorge]
I would make sure you have the best time of your life professionally and personally and I have fun. I will take good care of you.

[Jaz]
Listen as long as there’s red wine and meat. You have me.

[Jorge]
I don’t know if you know but my father has a seafood restaurant. And the restaurant is like 20 meters from the ocean. So I think that answers your questions.

[Jaz]
You had me at seafood. This is amazing. Jorge I think I’m gonna make that happen right? So guys, if you have in your mind and interest to come as a Protruserati maybe 15-20 of us something like that. Is that 15-20 too much? Is it okay? 15-20 of us to fly to Porto together to have some time with Dr. Jorge Cardoza and learn vertical preparation and have some seafood, then do this go to protrusive.co.uk/vertical. And let’s see how many people are interested. Now I imagine hundreds will sign up but then only about 20 about once they ask their wife or husband will, you know will eventually be able to come and the dates and stuff. So let’s put our feelers out, it’d be so great to have like, always wanted like a protrusive ski trip, but my wife doesn’t ski but this is, you know, somewhere in the sand, seafood. My wife is okay with that. So, you know, bring your family along, let’s make a little excursion. I’m actually really excited. So amazing. We will do that. Jorge, thank you so much for giving your time today. And I hope to see you with about 15-20 good friends who listen to the podcast in Portugal to learn about vertical.

[Jorge]
So Jaz, thank you so much. If that is a promise, I will not let you go by the sort of next year without coming here to Portugal.

[Jaz]
I love it. Thank you so much. I’m totally up for that.

Jaz’s Outro: Well, there we have it another cracker with Jorge Cardoso. Don’t you just love his willingness to share his failures, and those extra tips and advice that he gives that I don’t think any other educator has thought of. So thanks, Jorge, for delivering great value there. And if you want to come to Portugal with us, it’s not a done thing. Like I don’t know, it’s always been a thing on our mind that to get a group of like minded dentists and go traveling the world and learn from amazing clinicians. Right? So now that the world is opening up with COVID again, if that’s something you’re interested in, go to protrusive.co.uk/vertical-portugal and maybe I’ll keep you up to date you know, maybe we’ll see if something works out. I’ve got a feeling it will for maybe spring 2022. Let’s see. So sign up if you’re interested. I won’t spam you or anything but if you do want to join my newsletter for like up to date episodes, infographics PDF, then join that as well that’s protrusive.co.uk/newsletter, and I’ll keep you updated. Anyway, catch you in the next episode. Fingers crossed Wish me luck that I can put together their very very mammoth task of basics to occlusion. Okay, wish me luck, guys. Okay, I’ll see in the next one.