I Can’t Believe This Sticks – EXTREME BONDING EXPOSED – PDP077

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How to do Deep Margin Elevation? What are the most important factors in achieving high bond strengths for our restorations? I sometimes look at modern onlay preps and think, ‘God MUST exist’, because I think it’s a miracle how these flat, table-top onlays stay on! I am joined by a world-famous educator in Biomimetic and Adhesive Dentistry: Dr David Gerdolle

David Gerdolle, based in Switzerland, introduced me to contemporary ceramic onlays 8 years ago. It took me 3 years to convince myself the techniques would work in my hands! In this episode I want to fast-forward your progress so you can gain more perspective on adhesive restorations and DME (Deep Margin Elevation).

Need to Read it? Check out the Full Episode Transcript below!

Protrusive Dental Pearl: How can you show patients what shorter anterior teeth might look like to them discing them down? Use a black Sharpie marker, colour in the part of the edge (maybe 0.5-1mm) that you’re considering removing. Take photograph and show it to them! It helps if their mouth is open for the photo so we see the dark backdrop of the oral cavity.

With the knowledge of Dr. David Gerdolle and biomimetic dentistry, we discussed how it is possible to bond a material to the tooth structure in those ‘table-top’ style, flat onlays. 

It doesn’t happen magically. It’s about the nitty gritty detail, the micro steps and respecting certain criterias.

“If you don’t remember anything of your bonding protocol, just remember that, it has to be clean and rough” – Dr. David Gerdolle

Clean and Rough, that’s it right there!

In this episode, we also talked about:

• Failures in using biomimetic dentistry and what we can learn from that
• How these restorations have resistance form
• Bonding protocol step-by-step for adhesive dentistry
• Deep Margin Elevation – how to do it

As promised, DM me on Instagram @protrusivedental for the PDF copy of the steps of deep margin elevation.

 If you enjoyed this episode, then do check out Dr. David Gerdolle for more courses.

You might also enjoy Ceramic Onlays from Preps, Temporisation and Bonding Protocols by Nik Sethi!

Click below for full episode transcript:

Jaz’s Introduction: I know I’ve covered the theme of onlays before, it’s not new for us. But do you remember the first time you saw one of those onlays, the lithium disilicate onlays, which are like bonded on essentially what looks like a quite a flat tooth. And the first time I saw it, I was like, no way, this is not going to stick. I don’t believe it, I don’t buy it. I’m going to stick to my conventional crown preparations. But you know what, seeing these more and more now is great. And in my hands, they do work. And it needs a proper discipline and protocol, which we’re going to discuss today with someone who’s absolutely awesome. It’s David Gerdolle. And it was David Gerdolle around about eight years ago, I attended one of his Dentinal Tubules lectures live in London. And I just couldn’t believe it. That’s the first time I thought, whoa, this is crazy. This is insane. How could this ceramic stick to the tooth, it just didn’t make sense to me, right? But what I learned from that day has stuck with me for such a long time forever as part of my clinical protocols. And that is the following A) you just need a clean substrate and B) you need to have enamel. If you’ve got enamel circumferentially, these onlays can be extremely successful. And to take that a few steps further. I’ve got David on today to share some steps, just generally in just composite bonding and Emax bonding and the whole principles of adhesive bonding in general. And you leave with some real gems that you can improve your bonding protocols on Monday morning. We also discuss something that’s very topical and that’s deep margin elevation. So for those of you that don’t know, we’re going to cover it in the episode. But deep margin elevation, essentially, is when you have a tooth and you want to give it an ADHESIVE onlay therefore you want enamel everywhere. But maybe in one area, maybe at the depth of the mesial area it’s quite deep, and it’s quite subgingival. The problem with it being subgingival is that when you come to fit the onlay, it’s going to be difficult to isolate that rubber dam. So the way that we can turn something that’s subgingival into supragingival is by adding some composite in that very, very deep area mesially, which as you know has many challenges. But this whole concept of deep margin elevation, i.e., you are lifting that deep margin and you’re making it supragingival. David Gerdolle will do a much better job, I promise you of explaining it than I just did. But before we join David in this absolute brilliant episode. I hope you like the title. I Can’t Believe This Sticks – EXTREME BONDING EXPOSED because honestly, the first time I saw this, I just was absolutely. Honestly, the first time I saw this, I was absolutely amazed. And sometimes I still have it the first time I saw this, I was so amazing. Even nowadays on placing these onlays. I see them year after year after year. And I sometimes think to myself, is this really possible? How is this working? Right? But of course, it’s the science of bonding, which David Gerdolle covers beautifully.

Protrusive Dental Pearl:
Before we join David, I’m gonna give you my Protrusive Dental Pearl for today. It was inspired by a recent patient encounter I had whereby she felt as though that her lateral incisors were too short, and she requested for them to be lengthened. But in her so onload function, I knew that this will just lead to chipping, there was just a real lack of space, and it wouldn’t be favorable. So therefore, we delve deeper into the problem. And it wasn’t that the laterals were too small, it was up ahead her centrals which were bonded with edge bonding were too long. So before I took a soflex disc to the centrals to make them shorter, how can we show patients what shorter teeth might look like before we actually start hacking them down? Well, this trick I learned many years ago as to use a black sharpie marker for once, yes, I’m not using on splints I’m using on teeth. So you just color in the part of the edge, maybe half a millimeter to a millimeter that you’re going to be removing. And then you take a photograph, and you show the patient the mirror and against the dark backdrop of the oral cavity. It almost gives a patient and understanding an idea of what they might look like with shorter incisors. So in this case, we used a black sharpie marker to show this patient, okay, you know what, I think I want to remove half a millimeter of composite here. And then this might just improve the harmony between your laterals and your centrals and that’s what we did and she was happy. So I didn’t have to bond her laterals, which was going to be unpredictable without having orthodontics or increasing the vertical dimension. So this is a cool little trick when you want to communicate your patients what shorter teeth might look like. Protruserati, I’m not gonna keep you any longer. Let’s join David Gerdolle on I can’t believe this sticks: Extreme bonding exposed.

Main Episode:
David Gerdolle, it is fantastic and absolute honor to have you on this podcast. How are you my friend?

[David]
I’m very good. And thank you for having me. I have to thank you really.

[Jaz]
No, not at all. I think you’re going to give so much value to those listening. With a little bit of background about how I got to learn about you several years ago, maybe was eight, nine years ago, maybe it was your first encounter with Dentinal Tubules you came and you absolutely blew my mind with a presentation showing these onlays which I could not believe. I just couldn’t believe at the time that was sticking. So that’s why I named this episode, “I can’t believe this sticks”. Because even recently, I had a guest recently, Nik Sethi you might know him. He talked about the full protocol of ceramic onlays and we had a good discussion about that. And then he convinced me even though you told me many years ago, he finally also encouraged me. So to Jason Smith and all these great clinicians convinced me to start using heated composite instead of Panavia. So I did this recently, I posted a case on Instagram. And still people were asking questions like I can’t believe this sticks. There is not enough resistance, retention form on these. So even today, 2021 compared to eight years ago, people still have this objection. And so that’s what we’re going to talk about today. How can this stick, how’s it work, we’ll talk a little about the science of the bonding, and just what we can learn from you. But before I babble on too much, I want to do an introduction for you. So you have been so influential in my sort of career in terms of appreciating how powerful bonding could be, and you really opened my eyes many years ago. But tell us about yourself about the bio emulation group and about your definition of biomimetic dentistry?

[David]
Well, actually, the funny thing is that my first dental education with very traditional work, I was belonging to a Prostho department. So I’ve indicated drilling for crowns and bridges and a very conventional dentistry. And I am still thinking that could be for some cases, a very good dentistry and very good indication. So I don’t think that we have any war between biomedical and with conventional dentistry, it all can work together, depending on the patient and conditions. But the fact is that something like, 15, 17 years ago, I had for research, purpose to get more interest with the composite and stuff, and did some courses, especially with Didier Dietschi, in Switzerland in Geneva. And it was really like a revelation that we can just do something else. At the same time, we’ve got patient that are getting older and older. And we know that our treatment will not last forever. So if it makes the patient will die maybe in 100 years old, we still have to find solution when the patient will come back and do the 80 years old with a crown that has failed. So this is why I think biomimetic dentistry is just the best way to buy some time for the patient, meaning this is not a better dentistry. This is a very nice dentistry. But this is less invasive. So we just have all the cards to play for the future, maybe crowns, maybe implants. The problem is that if we jump right away for implants to a 40 years old patient, it’s a disaster, because still will live for 50 years. And we’ve got nothing left to propose to that patient. So I think this was the philosophy I was really seduced by. And then I met some guys, especially from the bio emulation group. And those guy are very, very interesting. First, they are brilliant, are amazing dentists. Well in England, Jason Smith, for instance, that is a very, very brilliant guy, very pragmatic guy, also very funny guy, so full of knowledge, and that this is the first quality of that group. This is just a good dentist. And at the same time, they are dreamers because they always trying to improve the thing and to find the best way to do the things but on the other hand, most of them are just private dentist, very normal dentist, so they have to earn money they have to live in the real life with their real patients. If you put all this together, this is very nice combination, of friendship, stimulation, with a nice experience and a nice proposal that we can do to our patients. Let’s drill a little bit less your tooth. Let’s try it and you know what, if it’s not working, we can still do something else, which actually you cannot do with the crown. Once the tooth is drilled off, it’s done, it’s nothing else. If the biomimetic solution fails, no problem, we can still move to something else. And the thing is that it doesn’t fail that much. So even better.

[Jaz]
You definitely infected me with that way of thinking all those years ago. And recently, I had the honor and privilege of reviewing one of your videos that you submitted to the series you submitted to Dentinal Tubules. And it was an absolute pleasure to see all your steps and you talked about veneers and how the detail you’re going into in bonding these veneers and rubberdam. And how much that can improve your results in certain ways and how you have to get around the common challenges of doing that. So that was mind blowing as well. So what I wanted to do was take some lessons from that and share it with the Protruserati, so the people who listen to this podcast are called the Protruserati. And I definitely wanted them to know about you if they don’t already they need to learn about because I think I’ve told you before we started recording, guys, if you haven’t heard David Gerdolle and stuff. He’s such a wonderful educator. His style of educating really appeals to me. And when I’m educating, I tried to model myself like David. So I just want to put that in there that I love it. I keep doing what you’re doing, because you’re really helping people understand this stuff. So I guess the first we can dive right in if that’s okay, David is the first question is, how can it stick? How does it work? Okay, but I don’t want to just answer about the science, I want you to teach me in a different way. Can you tell me about some failures that maybe you had early on, in using biomimetic dentistry, and then what we can learn from that, because if some dentists, young dentists are starting to use, maybe they’re trained more traditional way. And now they start to use and the first venture into extreme bonding or biomimetic dentistry, and what common mistakes they might make, and maybe some things mistakes that you have made in the past?

[David]
Well, I think the most common mistake is when you belong to wanting one type of education like your I don’t know, you are designing an inlay with some kind of geometrical retention form. And then you would like to drill a little bit less to why not bonding my inlays, I was just cementing my gold in these. Now I want to do composite inlays, ceramic inlays. And I would like to bond them and maybe I don’t need that kind of geometry. And the problem could be to abandon and to quit brutally, all the principle that we’ve learned from the past, meaning occlusion still exists, biomechanic of the tooth still exists. So it’s like, we cannot just trust the bonding system. And the composite in the composite is like something magical. And it will resolve all the problems. So I could just, I don’t know, don’t drill anything. It’s something like flat, no geometry, no retention, maybe no space, because I don’t want to drill so I have a very thin thickness of ceramic material. And then by magic, the bonding will just save my life. It doesn’t happen. So it means that we just have to do everything that we were doing before with all the precaution, with all the knowledge, with all the study of the patient, and especially the functional behavior of that patient. But then it’s true that respecting kind of certain criterias like, do I have 1.5 millimeters of thickness for my material? Can I work in a very clean conditions? Because we know that those hydrophobic product, they don’t behave good if we have moisture, ambient moisture or direct contamination? If the answer is yes, simple questions in criteria like those, I can just maybe switch to something that is bonded. And it can save one [course], maybe one millimeter  preparation, maybe one kind of drilling that is more invasive, that it’s not like, okay, I will change my mind now and do something completely differently. Because it’s still a patient, it’s still the same function. There are still teeth, and it’s the same, so I think this is the most common mistake and say it this is bonding, this is magic. It’s nothing magic and bonding.

[Jaz]
So as to follow this still not to forget the fact that the material still needs a desired thickness to respect the occlusion as you say. And just because we can bond so well. You don’t just purposely make your preps flat, you still build some resistance form into it. So what advice can you give to someone who’s starting out with onlays posteriorly, maybe out of ceramic, maybe lithium disilicate, leucite, whatever. How can you impart some natural resistance form without drilling too much and then making it look like a traditional prep? Any sort of tangible advice you can give on that?

[David]
I would say two simple things. Make sure that you have at least 1.5 millimeter, because most of the thickness, because most of the restoration, the posterior level, we have existing cavities, we have amalgams we have stuff like that. So it means that 90% of the cavity is represented by dentine. Dentine is something soft, it’s kind of trampoline, meaning that for this kind of lack of stiffness, of the support, of the dentine, of the dental tissue, we have to compensate with the thickness of the inlay so that when we see fancy inlays, 0.3, 0.5 thickness of ceramic on Instagram, it can work if it’s bonded on enamel. So if it’s Niroshan case, bonded on enamel, which is very stiff, it’s okay we don’t need two millimeters that most of the time, which is that on dentin. Dentin is soft, so meaning 1.5 at least, you can easily achieve that using like the penetration control technique or something like that, using specific burs or a bur, you know exactly the working part is two millimeters. So I put my bur entirely in the cavity so that I can make sure that I have those 1.5 to two millimeters. This is the first thing I would say make sure that you have definitely some thickness for the common cases for the daily cases. And the second thing to make sure each will definitely bond, I don’t think there is a proper geometry or way of let’s say a chamfer is better than a bevel or we don’t really know the people, they do really different things, it looks like everything is working. But at the end, it’s the way we will bond them. So it means if those substrates composite, ceramic, dentine, or clean and rough, you can put whatever you want any kind of composite, it will be good. So it means that the material has to be thick. And if it’s bonded properly, it will be resistant and it will not fade because one of the most common way to see that the bonding was not good is a fracture of the material. Because actually, doesn’t the bond is almost never the bond. So the kind of failure is a “Oh Doc, I just lost my inlay.” No, it doesn’t happen.

[Jaz]
Cohesively, do you mean like a material cohesive failure?

[David]
Exactly. This is a material failure that we have like a fissure fracture of the material. The translation of that isn’t or I didn’t do the right choice with the material is my inlay would maybe too thin for the kind of substrate I had in the cavity dentin, or it was badly bonded, bad bonding, bad resistance of the material. So this is like the demonstration that my bonding was not good and then the material did fracture. A proof, a very easy proof of that we’ve used for years feldspathic ceramic, can you imagine feldspathic ceramic? So brittle. It’s a fragile, you’re looking at feldspathic ceramic is breaking already. So it’s no resistance at all. But if you bond it, it’s unbreakable. So it’s not really about the resistance of the material. Of course, it helps. Disilicate is much more resistant, so it will forgive many mistakes very good. But we don’t really need the more and more and more resistance we need to have a minimum of a thickness and to make sure that we are bonding okay, in a very efficient way.

[Jaz]
And that’s it. Protruserati, it’s Jaz Gulati interfering with this very important message. Splint course is open for enrollment again. This is the course that I released earlier this year, we’ve had phenomenal feedback. I’ve been just absolutely blown away by the feedback from all over the world. This is my course to teach you how to prescribe, diagnose and deliver splints that will help your patients with headaches, myofacial pain. For patients to stop breaking your restorations, and for patients to help them to get their muscles relaxed prior to complex restorative work. So if TMD confuses you, if during the whole muscle examination and deciding which splint to use, when and how, then this course covers it all. From the theory to clinical videos, but don’t just hear it from me, don’t just take my word for it. Here are some of my students for the next couple of minutes just talking about their experiences with the online course. And then we’ll join David Gerdolle again who’s just already blowing our mind with bonding.

[Protruserati telling about the SplintCourse]
I absolutely loved it because it’s modular. And it’s broken down into little segments that are not too long, really easily digestible. So you can stop and start whenever you like, and you don’t feel trapped into learning all in one go. And I don’t think people learn very well that way anyway. So some people who do like doing that, can sit there and just be stared over a couple of days. But you allow me as a new dad and busy guy working and stuff, just to do it gradually over the course of sort of five weeks. So yeah, it’s really good being modular, and Jaz explains it very, very well.

[Jaz]
So if you want to start implementing splints and occlusal appliances into your practice to help your patients with pain and help them to stop breaking your restorations, and come and join us on Splint course, and I’ll see you in our secret Facebook group where we can support you and go for monthly live coaching. Brilliant, all that leads very nicely just a side question, sidetrack you is, which do you believe in more? Do you like to? Is it case dependent? Or do you always like to once you remove your amalgam? Once you do your cusp reduction? Do you like to build up a core and then prep back? So you have an even thickness of the material everywhere? Like some can they believe this? Or do you not mind that in one area your lithium disilicate will be three millimeters and another area might be 1.5 millimeters by not building up core, which do you do and why?

[David]
This is an excellent question and a crucial question because much more than the intrinsic resistance of the material or its thickness, if the uniform thickness that is that will create the resistance of the material mostly, we have many papers on that. So it means that by definition, in a cavity, you don’t have a uniform thickness because for some part you have five millimeters on the other part you’ve got one millimeter. So it means that sometimes we have to drill if the cavity is only one millimeter deep, well, this is not enough. So we might drill a little bit and compensate on the other side with a core building with some composite doing the immediate dentin sealing, just to try to make it a little bit more uniform. So we don’t have to trim, it’s impossible to do like something that is two to three millimeters super uniform, it doesn’t mean that we have to put three millimeters of composite at the margin because it will ruin completely the emergence profile, and we will discuss that point a little bit later. So it’s not a good idea either, what we just have to do is to try sealing the dentine to compensate a little bit though thickness to reduce the huge difference of thickness and to also raise completely angles. Because this is what will make the material fragile, difference of thickness not uniform, and also variation of angulation. Think about a vinyl with the occlusal part and the buccal part. If you got something quite thick at the occlusal part and super thin on the buccal part with a very nice 90 degrees angle between those two parts, it will break just in between. It just like automatic, so brutal change of angulation and brutal change of thickness is not good for the material. If we can compensate this a little bit with the form the morphology of the prep and with refilling the cavity with some composite doing the immediate dentine sealing. Perfect.

[Jaz]
Amazing. That’s a very comprehensive and direct answer. I love that, micro step. So dentistry is all about the nitty gritty detail the micro steps. So if you wanted to give the dentist a message in the most important of micro steps that that will get you the best bond. So like the Pareto principle, right, like 20% of your efforts give you 80% of the results. So what do you think is the 20% of the bonding, that will give you all the steps in bonding that will give you the 80% results even if you mess up the other steps?

[David]
Very simple. If you don’t remember anything of your bonding protocol, just remember that it has to be clean and rough, clean and rough, any substrate, anything you are facing could be ceramic, metal, composite, dentine, enamel, whatever you want any kind of substrate, if it’s clean, meaning no organic chemical species on the surface and rough meaning micro rugosities, this is just perfect. So there are many ways in different ways depending on the material that we have, to this clean and rough that it’s clean and rough, you just put composites in between those two substrates it will bond. So usually we are sandblasting depending on the material can be a different kind of sandblasting. But sandblasting and etching, acid etching, we have different kinds of acids, depending on the material to different kind of acid period. It could be 20 seconds, one minute, one minute and a half. That basically it’s always the same. So I think this is the 20% that represent the 80% of result for sure. It’s also very good news, because it means because always the question of the dentist is that “Oh maybe I don’t have the good composite, maybe I have to buy a new one, a new box with something new or I don’t know any company came in my office yesterday with a brand new one and showing great numbers of adhesion.” Well, one of my mentors always said, you know what, you just have to calm down a little bit because even the worst adhesive system is enough. It’s okay. And nobody will die. So I think I can work with the products I like because I like the viscosity, because I like the color, the opacity or I like it. It will be okay if it’s clean and rough. If it’s not clean and rough, you can just purchase the best of the best material of the market. The success is not guaranteed.

[Jaz]
Guys, can you see why I like David’s education style so much. He’s so direct and I just love the way he says things is amazing. I love that answer. Fantastic. So clean and rough, guys. Keep it clean and rough. The next question I want to ask you because we’re doing really well here is something that no matter you know, I had Jason Smith on the podcast we talked a little about DME, deep margin elevation. We started the podcast, yet still the number one question I get from the Protruserati is always surrounding elements of deep marginal elevation. So for those who don’t know I will let you explain because you do a much better job than I will. But what is deep margin elevation so if you don’t mind just describing to the dentist in the way that only David Gerdolle can. How would you describe to the dentist what is this deep margin elevation?

[David]
Well, deep margin elevation is a very simple idea, you have a deep decay. A decay that it extending beyond the gum level. So we are subgingival, we noticed that it’s very difficult to clean it, to get an access, to do the impression, to do the provisional or to eliminate the access. So, we have two solution, conventional solution, I will do a crown lengthening I will get something, get some gain, get some bone just get an access and facilitate my life. So, this is a very good technique, the only problem is that most for the if we are talking about posterior teeth, for instance, the deep caries are proximal. If I get proximal, some gum and some bone, I will lose the papilla forever. So whatever the emergence profile I will have, the patient will have food stick stuck in this area, and it will never be at it was before. So, we in that sense, we thought “Oh, this is not me inventing the deep margin elevation, the Swiss guys like Didier Dietschi, Pascal Magne, they thought like 25 years ago, let’s do something else. So, if the problem is the deepness of that margin, so cervical, so close to the bone level, could we maybe raise up the margin with some material, this is the margin elevation to change the level something that is like equigingival level, something like that. And with some kind of material, when the day we are prepping the tooth, can we do that and then it will facilitate the impression, the provisional, the fitting, the elimination of the excess when we will cement the inlay next week.

[Jaz]
So the isolation so much easier as well.

[David]
Exactly. The first isolation is really a pain in the ass. And the second one is easy peasy. So this was the idea. And they started to do that. So I remember very well, when I came in Switzerland, it was 2005. I didn’t know anything about margin elevation, didn’t even know the name of that. And doing one course with Didier Dietschi, he was telling me, he was teaching about it. And I say “wow, you know it’s something strange for me this double margin, what is that?” Is it you know what the problem is not the double margin. Because the double- the problem is, do you trust bonding on dentin on a proximal area? Yes or no? If you don’t trust, do the crown, do a gold inlay cemented with phosphate. If you trust, can you tell me the difference between a composite luting cement here, two millimeters subgingival and a direct composite here, two millimeters, subgingival. This is composite bonding in the proximal box. So, if you believe that this is possible, why shouldn’t you do margin elevation? And I say, oh, yeah, this is true. And then I started to practice this technique. The problem is that when Didier is doing that, this is very easy, it looks like it’s okay, but he’s a genius, but not everybody is the Didier Dietschi. So in my hands, it turned out to be a different kind of outcomes. And so this is the magic either, but this is how it works. This is what is margin elevation. The idea is to avoid surgery, change the level of the margin, adding by adding some material.

[Jaz]
Brilliant, you explain that fantastically. Now, in my own experiences of DME, deep margin elevation. I do believe in dentine bonding. So I’m happy to do DME and it makes my isolation so much easier, as well as all the benefits you said. So I believe in it. However, my one concern and my one element of case selection, when I emailed you is that if some, I know we shouldn’t be doing anything indirect and someone who has poor oral hygiene. So I don’t mean poor oral hygiene, but someone who’s just never 100% at getting the plaque at the gingival margin. They’re doing okay, they don’t have periodontal disease, they’re almost resistant to perio. But they’re just not fantastic. Over the years of getting their gingival inflammation low enough. And this is the real world. We all have patients like this. In that patient, I am less likely to case select for DME and go onlay. And I’ll probably just do the traditional method. Nowadays, I might do something that’s trendy or verti prep or something like that. I don’t wanna get into that too much but what do you think is my case, am I right to be case selecting these group of patients who are not amazing at the gingival inflammation and their general to oral hygiene, or should I be a bit more brave and do it on those patients as well?

[David]
I would say Yes and No, it’s a very smart approach. And I did this mistake myself not being that smart. When I switched to margin elevation and to bond industry, I did it because this is kind of my character, it’s I am a black and white guy. So it’s like, okay, I quit with the crowns. And I will do 100% of adhesive dentistry for everybody. Because everybody is deserving and this was obviously completely stupid. And for some patients with poor oral hygiene, or maybe they have a very good hygiene at 60 years old, what is happening at 80 years old, not anymore. So the patient can change, the bacteria can change, the tissue can change, the elf can change, the patient resist, and one day he doesn’t resist. So it means that we had numbers of failures about that not really, with the technique itself. But with the indication, bad indication for bad patients. So I think you’re right. There are two levels of question. The first one is, what about the patient? What is this patient looking like? If it’s, let’s say a good candidate for bonding dentistry, because I know that is coming regularly to the recall with the hygienist with the depth recall program and is really performant with the oral it is motivated. So why not doing adhesive dentistry? If, this is the second point, I am just able in that case, as a dentist today, Monday morning to do a proper adhesive technique. And this is an I have to answer. Yes, this is a good patient. And yes, I am a good dentist today for that patient for that tooth. So this is not like a general answer. Some kind of patient they don’t deserve. I don’t know above 70 years old, no margin elevation. No, you can have very good elderly patient no problem and very bad young patient. And it’s not like it’s for you the super good dentist or the super bad dentist because the same dentist the same day can be a Monday a very good one. And on Tuesday, the worst dentist on the planet. So it’s like I am able to do properly my work. This is a good indication a good tooth for that and the patient is able to just clean it properly. If it’s a yes, yes, it’s okay. I go for it. If it’s a no, yes, yes. No, I don’t go for it. And I move for some conventional technique. As you mentioned, vertical preparation crowns. Perfect. That simple.

[Jaz]
Brilliant and I think I’m hoping that question and the answer you gave will start getting dentist to think a little bit more about case selection and not just always just seeing, deep caries, dentine and always automatically going towards deep marginalization. Just take a step back, look at the patient as a whole, just like all the things you said. So that was a very great answer. I appreciate that. The next thing I want to talk about is the now that just defined to wrap up the episode, the nitty gritty details of how to successfully carry out deep margin elevation because anything subgingival is more difficult. We know that and a of dentists mess up saying you know what, I tried it, it was a disaster, it was a mess. I‘m never gonna do it again. So one thing that I have found David, and we haven’t rehearsed so we haven’t talked about this so I like to use a thermal cut bur, which is diamond, I like to just get rid of the papilla. So I’ll do papillactomy, that will allow me to get my rubber dam down and then able to get a more predictable seal with my matrix band. Is there a way I could do it without having to destroy the papilla? Are there any different ways that you can a tip that you can give us for a dentist who are doing deep margin elevation? And if you don’t mind this one last one more on that, and I’m happy to repeat these questions is, which is the best composite in term of viscosity to use in these scenarios? Is one of those, like g-aenial flow good enough in that region? Or is it to flowable?

[David]
So first of all about the protocol, people coming into some details or tricks. I just would like to mention maybe what are the goals? We should reach at the end for a good margin elevation because I told you, if today I’m able to do that I’m the good dentist. What is a good dentist in that case? Well, I think that the good dentist is the dentist able to isolate properly. So it’s something that can be really hard because it’s really down the gum level. So isolating good, meaning I do my isolation and during the procedure I can see that it’s not sealed. I will not do margin elevation using your composite or stuff like that because I know this will be a filler by definition, then I am able to place the matrix yes or no. This is also very difficult to get the matrix down to the margin and seal at that level. This is also a problem because we cannot use for most of the situation. No, it’s-wedges. Sorry. So the thing is that for most of those cases, we are not able to use wedges, because which is more or less, they go always are horizontal, maybe a little bit curved like that, but it’s horizontal, and the decay is never horizontal is always concave. So most of the time, I need something to push my matrix in to see my matrix towards the teeth. How can I do that, and this is why I don’t personally cut the papilla because the papilla can save my life, the papilla can push on the other side of the matrix. Of course, the papilla is complicating my life when I want to push my matrix in. But then once the matrix is in the papilla can help, the papilla is my wedge. And I can reinforce maybe the papilla effects with some Teflon tape packed on the external part of the matrix. So isolating, putting the matrix making it seal and then matrix with the good emergence profile. This is also very difficult because naturally, the matrix has a tendency to go vertical, and the emergence profile at the surgical aspect is always a bit divergent. So I am able to achieve that. And finally, when I will refill that space, that box, that property, that proximal box with some composite, am I able yes or no, to refill it like one shot, it means afterwards, I would not have to finish with strips and burs. And I don’t know what because the problem is, once we start to finish, I’m thinking about polishing and final polishing just finishing, I got an excess, I have to go to get these access with the strip, we will roughen the surface. If we roughen the surface of the material that bacteria adore, it’s a problem. Because it makes it creates automatically bacterial retention. So it means that the good dentist is able to isolate, put the matrix, seal the matrix and diversion profile, a good emergence profile, and just like more or less the one shot refill of the cavity. If it’s the case, it’s completely okay. And you can use whatever you want. I think that the best material is the best composite that we have the best composite meaning in terms of properties is the restorative composite. Restorative composite, viscous composite is always better than flowable composites. Flowable composites are more convenient to use, restorative composite a little bit more tricky to use. So this is why we can maybe heat them up a little bit to make them less viscous and facilitated the handling. But or maybe mixed both of them a tiny bit tiny to flow so that we don’t have too much polymerization shrinkage and then go with the restorative composite. But I think that if you want to refill two, three millimeters in a box in the proximal box, doing everything with a single increment of flowable is a bad idea. Because unfortunately, flowable is not the best composite ever.

[Jaz]
So how about HRI composite? It’s very stiff. I had one dentist always prefer– t message me saying that she sed HRI and she really struggled. And she asked me, “Jazz, do you think I should have used a slightly softer composite?” And I said I don’t know. But I know someone who knows the answer. So David, do you think a super stiff composite sometime the Venus maybe it’s quite stiff? Sometimes the HRI very stiff? Do you think something even when you heat it, it ca be quite stiff? Do you think I’m slightly softer? restorative composite might be the way to go?

[David]
If you can really heat them up. Usually I heat them up. It’s like 65 degrees for at least 10 minutes before you’re using them. Most of them they really became softer. And you don’t have 10 minutes to enter them and to enter with them. It’s like 20 seconds or something like that because it gets hard again, and viscous again very, very quick. So it’s like I take it out of the compule, and I try to put it into cavity and I have maybe 10 seconds of comfort to apply the composite, the best way I can. So, it facilitates a little bit my life. But again, I think that the priority is not really the kind of composite This is the way I can use it, I will give you an example, the injection molding technique of David Clark, very famous technique, and I say you put flowable and then restorative composite all at once and perfect polymerization, two minutes, no bubbles, no voids. And you say the first time I saw that is this is crazy in terms of shrinkage and everything, it would be a disaster. The problem is that if I am trying to do the alternative technique with very, very small increments and pushing my increments and polymerizing it at the end, I have bubbles everywhere. So, bubbles is a bigger problem that may be a little bit of retraction. So it means that if the only thing I can do, the only way I can achieve a proper refill of a proper filling of the cavity is by injection molding, injection molding is the best technique. If I can do it with small increments of composite without introducing any voids, this is the best technique. So, again, this is about the operator not really the technique. And I can tell you that some days, I’m not a big fan of the injection molding technique. I never do it in like at once for all the cavity. But for some tricky cavities with a very difficult access, I’m using it. Because I know that even if I’m losing a little bit in terms of contraction, I will gain on the other side by refilling some very tiny, very sharp zones that I cannot reach with the conventional technique. So we just have to adapt and to adapt to the dentist of the day, the ability of the day.

[Jaz]
And that’s brilliant. I love that fantastic. I think what we can do now is maybe just share one example of a deep margin elevation. And for those who are listening to podcasts, I probably have to direct you to the YouTube version to see this bit. And then we’ll come back and do our goodbye and how we can learn more from David. So maybe if you start sharing the screen and show a case. In the meanwhile, I want to ask you a question while you are loading that up. So when you have that deep margin elevation, maybe you will show in the photos. Now, when you apply the rubber dam, where you are very deep initially, the rubber dam is not fully seated in that area. So you can see the gingiva in that area. But only when you apply the matrix, can you now get that deep margin acquisition, you can acquire that deep margin? Is that generally the way you do it? And maybe you’ll show me now in the photos, I think.

[David]
Yes, because I think on that example with gut, I will jump directly to the clinical example. And it will be maybe easier to explain. So this is actually the moment, that moment, you put the matrix in its position. And you want to see the matrix that is sealing quite nicely the margin of the preparation and with a nice profile. And let’s check that everything looks okay. It’s never okay, because this is, even if you’re working with a microscope, and something like 15 times magnification, we know that this is not perfect, but it’s looking sufficient. And okay. So look at that case, which is kind of difficult one from the initial X ray, you can immediately see that you will sweat a little bit redoing that one because it’s almost bone level. Some tips and tricks here that can be very useful is that just put the rubber dam from scratch. If you take because the natural tendency is to remove first the filling, the existing filling, and then it looks easier to put the rubber dam in its position because we don’t have any proximal contracts anymore. But the fact is that the existing walls of the cavity, the existing proximal walls, even very bad walls done by the existing amalgam will guide the rubber much deeper. So put the rubber dam before removing the old restoration. And don’t remove the old restoration before putting the matrix in because again, that part of the distal amalgam on the six can guide a little bit the matrix band. So at that time, because this is a quite an old case, we didn’t have a specific matrix band to do the margin elevation. So we’re cutting some conventional bands and trying to customize them, I will show you the anatomy of those bands in a minute. But some help of the existing wall, which are supragingival, we can try to put the matrix down. But this is a problem because we never know what happenedwe are pushing with the finger as deep as we can, but nobody can tell us at that moment, okay, your matrix has reached the top of the cavity, and the margin of the cavity. So and this is actually the problem, the kind of bands that we are using mostly, and we will see them also in a moment as those Slickbands of Garrison like banana bands with a great curve. And this is helping to get a better seal and a better profile. But what happened is that you put your matrix before removing the definer part of the existing restoration. And this is what happened. Maybe we were just kind of gum or latex or something in between. Yeah, it happens every day, and you just want to die at that moment. So if we can keep calm for a moment, and hold on, what we can just do at that time is trying to push out the rubber of the cavity. So the usual tip to do that is not to go with the instrument, from the inside to the outside of the cavity pushing it out, is to come from the outside, we have to pull it out from the cavity and it works much better. And at the end, we have something like that. So for that case, as we previously said, it’s impossible to place at that level, at that deepness, any kind of wedge it doesn’t work. So it means that this is the tension of the matrix that is doing the sealing. And it’s also maybe something that I can place outside of the matrix here, we can see some Teflon tape that is pushing a little bit, meaning that the sealing anyway, when it’s very, very, very deep, it’s not very powerful. If I push very hard right away with the restorative viscous composite, I will open my matrix, and we lose the sealing. So for that reason, maybe it could be prudent to start with the flowable composite that will not push away the matrix and then refill the rest of the cavity with the viscous one. So we do the adhesive that time with the octave on the fel. So this is the layer of gone defended a tiny bit of flowable at the cervical margin, just to ensure that the sealing will not be disrupted. And then we will fill the rest of the cavity with the composite, but we can see very good on the underside that the profile is not good, the profile is super vertical, it will not work. So we are trying to do something to push the matrix away and to make it more divergent, with kind of instrument polymerizing at the same time. So it’s really a fight something that you’ve got your you’ve done your gym, you know that day, you don’t need to go to the gym, it’s already done, because it’s something that were difficult. And at the end, well, you’ve got something that should be divergent. So again, the matrix that are those banana matrix are the best. So the one I’m using the most is the SlickBands of Garrison. And you’ve got also another brand, I think it’s an American brand called Grater Curve, that is also very good. And what happens is that you put the concave part of the matrix towards the cervical margin and the convex part of the margin of the matrix towards the occlusal part and automatically here you can see on the right, with the tofflemire retainer, the matrix will just put itself divergently. So it’s very interesting to get that profiling to improve the marginal sealing because again, we cannot really use wedges to do that. So it takes time, I cannot tell you that is something easy to do. And at the end, we always wanted was really difficult to control with some x rays because it’s impossible to see what we’ve done down there. It looks quite okay. We don’t have any idea of the efficiency of the sealing and bonding down there, but we can just pray and hope that it will be okay. The profile looks like not a natural profile. But let’s say that it’s okay. And of course, during the second session, it’s really really easy. Super easy to isolate, it’s super easy to put your inlay. It’s preheated composite, which makes also the elimination of the access pretty easy. And you can see everything and you can check everything. And this is really nice. So this is the big advantage of the margin elevation, avoiding surgery, and maybe we can keep the papilla in its initial position, which is very interesting for the comfort of the patient, less invasive, less money, also less expensive. So it’s very good for the patient anyway. And it facilitates the life of the dentist during the second appointment, especially when it’s time to eliminate the excesses. So this is what we have on that one. This is a pretty old case, but the X ray is very recent, because I just saw that patient with a seven years follow up. So it looks like it’s quite okay. But the question is always, we don’t see any recurrent decay, we don’t see any bone loss. So we can imagine this is a success. Well, this is a success. Yes, you can see it, the papilla is still there. But I think that that is leading. Okay. We have some other let’s say questions, raising up like, what about the distal fissure? In the six, in the seven, in the second molar? What about the choice of the material, this is lithium disilicate. And we can see as always, that the lithium disilicate doesn’t wear at all, and the natural tooth is wearing down. So what can we do with that? So it’s, let’s say a compromise. It’s not a full success, in my opinion. But in terms of margin elevation, this is not so bad. And this case, it’s just interesting for that reason, because when I started with this technique, my two biggest fears were, the patient will never brush, will never eliminate the black down there. So it means that we will have plaque retention. So automatically after a couple of years, as we know that this is not the best dentin to bond on, we will have a recurrent decay. This, we didn’t see that. So I don’t know why, honestly, maybe because we don’t have the proper bacterias to make carriers down there in the sulcus. I have no idea.

[Jaz]
Maybe the gingival crevicular fluid helping us, we don’t know. But you know, this is one theory I’ve read as well.

[David]
Exactly, exactly. Could be. And my second problem with, this is a clear violation of the biological width. Because we don’t have those two millimeters of collagen and connective tissue and etc. It disappears completely. So what about putting a material almost bone level, we will lose bone, and we don’t lose bone. So I’m not a Perio guys, so I don’t have clear scientific explanation neither I can just tell bout experience that those problems we don’t have. But all the other problems struggling with the emergence profile with everything we have. So this is maybe one of the most difficult technique I know, actually. So again I think that it should be done. Only when you feel that the patient can ensure a proper cleaning and that the dentist is in a good day. If we have those both things is a very nice technique. But it looks great. It looks easy it but it’s not. It’s not. And it’s not I’ve done five hundreds of those that it becomes easy. I can tell you that most probably the one I will have to do tomorrow morning will be super tough. And I will sweat like crazy doing it.

[Jaz]
It’s just yhis is why I get so many questions sent in to bring on a difficult guest like yourself, even though we’ve covered DME a little bit not in much as much detail as we went through today. But this is a big pain for dentists because there’s so many nuances struggles, like sometimes if I remove the papilla and I and you taught me something today, I might not remove the papilla next time because I see what you mean about the papilla supporting your matrix band. I agree with you. And I will try that because usually what I’m doing is one thumb I’m keeping really tightly on that matrix as I’m trying to hold that seal. So you’re right there’s the gym workout for the day is done and David you’ve done this episode so much justice. I knew you’d bring so much value. And you certainly have you’ve covered all my questions, and you are a phenomenal guest. I know that this episode will explode on YouTube and counting views on the listeners who listened on in a while they chop onions, while I gardening, while they’re driving that kind of stuff. David, here can we learn more from you? Where if someone wants to follow you on social media or earn more from you, and they like I do enjoy your teaching tyle? Where can we find out ore from you, my friend?

[David]
Well, I used to have a website that was up to date before COVID with the list of courses and everything, so I hope that a couple of months I can set up everything because I had to change it almost every day because everything is canceled and postponed. So you can go on the www.davidgerdolle.com and you’ve got all the details about the courses. But let’s say that we are praying on Instagram and Facebook to publish regularly news about the courses that we can do. And I’m working also with some universities, especially in France and Spain. So we’ve got some educational program in French and in Spanish in Paris, in Madrid especially some of the people and unfortunately, not in the UK But I would like to come in the UK to start some educational programs too, you have no problem. Traditionally, the Brits are the forever enemy of French, but I’m out of them, I’ve got no problem with the Brits. So please welcome me as I would welcome you, no problem.

[Jaz]
Absolutely. You’re very welcome to UK every time you come to UK, and I’ve been you know, so great that I caught you all those years ago, eight years ago, and you really opened my eyes to bonding. So thank you so much for having that influence in my career. And I know you’ve really touched a lot of dentists in this episode. I’ll put all your links and stuff on my website when I launch this episode. David, thank you so much for adding so much value. Appreciate it. Thank you.

[David]
Thank you very, very much.

[Jaz]
So that’s it. That’s the episode everyone. I hope you enjoyed that with David Gerdolle. So if anything, just remember, clean and rough. If you want to do some good bonding, make sure it’s clean, make sure it’s rough. So I hope you enjoyed that as much as I enjoyed talking to him. Honestly, David is just inspirational. I love seeing his work. And there’s a really cool handout I’ve made for you, showing you all the steps of deep margin elevation. I’ve put it on Instagram. So if you just direct messaged me on @protrusivedental, we’ll send you the PDF file. I’ll also add it on our telegram group, which you can find on the website. I’ve also.. I’ve got, I can’t be forgot to tell you this. Every single Protrusive Dental Pearl up to Episode 75 is now on the website. So there’ll be like a banner at the top saying Protrusive pearls click on that you can download every single Protrusive Dental pearl beforehand. So I hope you enjoyed that jam packed episode and I’ll catch you in the next one guys.