Immediate Dentine Sealing Tutorial Part 1 – PDP173

Jaz’s Introduction:
Now, part of the learning process, I learned about immediate dentine sealing, which is what today’s episode is all about. And I’ve been doing this since about 2015. It’s something I implemented in my protocol because I went on a Jason Smithson course and I saw that he was teaching it and he recommended it. So me being a good listener, I said, okay, if Jason says do IDS, I did IDS.

But over the years, the more lectures I’ve been to, the more literature I read, the significance and power of immediate dentine sealing really cannot be underplayed. In terms of the improvement in your bonding and the overall success and longevity of restorations just makes a lot of sense, which is why I know you’re going to love this episode with Dr. Zahid Sheikh, all about immediate dentine sealing, step by step, every little geeky detail will be covered, but more importantly, whether you’ve never done IDS before, you will feel confident to do so.

And if this is something that you do all the time, you get to understand a bit more of the rationale, the science, and the alternative options, different ways of doing it. Zahid does it differently to how I do it. And so you get to listen to both views. In fact, this episode was full of so much goodness, I had to split it into two episodes. So in this episode, we’re focusing on the preparation appointment. How do you actually perform the immediate dentine sealing?

And then the part two. will be the fit appointment. You’ve got your lab work back and now you’re going to remove your temporary and then reactivate that IDS, whatever that means. You’ll figure out what that means. We’ll go through it in extensive, protrusive style detail.

Now, these two episodes will be part of February’s Adhesive Month. That’s right. I’m reintroducing themes for 2024. I think a few years ago we did it. We had like Splintember for September and we had Straight Pearl for Orthodontics. So February will be Adhesive Month. And so 50 percent of any month, the episodes will be on that theme. One of the reasons I wanted to reintroduce themes for the whole year is to mark a huge change that’s happening in protrusive.

We’re actually launching the new app. So the existing app that we have great place for content, but you know what’s lacking in the existing app, which is why I’m moving next week and I’m bringing you all with me. I’m absolutely upgrading the protrusive experience. It’s all about people. It’s all about you.

It’s all about the Protruserati. It’s all about community. You see, all those years ago when I made the Facebook group, I literally thought only 200 people would show up. And every now and then I might mention the Facebook group, and you guys go out your way to find it and request your access in it. And now we’ve built a community of 3, 200 dentists, which I know is not a crazy number, but what I love about our little group is that everyone is so kind and geeky.

And so the philosophy of the new Protrusive Community, the new platform we’re moving to, is the home of the nicest and geekiest dentists in the world. You see, when you join a new Facebook group, very rarely do you see, Hi, my name is Ian, I’m a dentist from Newcastle, and this is what I like.

But on the app that I launched last year, dentists have been doing this. They’ve been introducing themselves and it’s been so nice to see that. Together we’ve built a community where everyone feels safe with each other and everyone tries to embody the values of being geeky and being nice. So thank you so much for sticking with Protrusive for all these years.

If you’re a new listener, thanks for joining. You kind of get an idea of what we’re all about. And I welcome you all to join the new app experience, the new platform, the new online platform which you can access on your desktop, on mobile. It’s called Protrusive Guidance. You guys actually helped me with this name.

Protrusive Guidance is going to be better than Facebook. Facebook is somewhere you go for convenience and there happen to be dental groups and you post on there, but you keep getting distracted by auntie Vivian’s birthday and the cat videos and Mark Zuckerberg watching you through his webcam and all the ads and stuff.

And I also feel bad about all the dentists who mess with me that say I’m not on Facebook. How can I access more of the community features? And this is where the magic is really going to happen. And the thing that I’m most excited about is the search function. You know I’ve been frustrated in my own app that the technology doesn’t have a search function, so I’ve upgraded it in a huge way.

This is going to be so beautiful, so clean, and I can’t wait to welcome you there. So let me just go through the rest of the year’s themes so you know what’s going to be happening throughout 2024. Okay, so February is adhesive dentistry. And part of every month we have an episode with student Emma Hutchison.

She’s the protrusive student, if you like. And we’re going to be putting some stuff out specifically for students, which you guys can join into as well. But like revision notes, Emma’s notes are awesome. So watch out for that. So every month ties in with some revision notes. Next month, March will be documentation.

So photography, videography, and even record keeping. How can we improve all these facets? April will be all about mental health. It is, after all, Stress Awareness Month, and I’ve already recorded some great episodes I cannot wait to release in April. In May, we’ve got a cheesy one, it’s May the 4th to be with you, it’s orthodontics.

Before a meaty one in June, it’ll be crowns and onlays, and in June, I’ll be taking a group of dentists to Sicily to learn from Marco Maiolino on vertical preparations, and that actually ties in quite nicely with the theme of crowns and onlays for June. In July, we’ll do periodontics. God help us all. It’s more of a service for you guys because this perio is not my biggest thing in the world, but you know what?

It’s got to be covered, right? It’s the foundation of all our restorative dentistry. In August, we’ll be covering removal prosth so we can all lift our game in our dentures. Before the true love occlusion in September. That doesn’t mean that there won’t be occlusion all the rest of the month. Remember, I said 50 percent of the episodes that month will be that theme.

But we’ll really go for it in September into occlusion. In October, we’ve got a huge one again, communication. I’m going to make sure that the guests that we get on in October are going to help us to become better communicators, not only with our patients, but generally in life, because communication is powerful.

In November, I’ve got oral med and oral pathology planned for wrapping up 2024 in December with a dentist life balance. So we’ve got a lot of exciting stuff. Look forward to this year.

Protrusive Dental Pearl
This episode’s Protrusive Dental Pearl. Every episode, I’ll give you one top tip, and this month is a communication one on Friday. Just a few days ago, I was lecturing in Cheltenham, a beautiful race course and my topic was bruxism and the restorative dentist. And now, and again, I, I like to just walk up to some of the delegates and I was speaking to one of the delegates who work nearby, very experienced dentists, and we’re just talking about the longevity of work and how proud we need to be that our work can last so long in someone’s mouth.

And we discussed this scenario whereby you have like a long standing bridge been there for like 20, 30 years and eventually it fails and the patient will be upset because they’re mourning it. They’re mourning the loss of their bridge that’s been there for so many years.

But we sometimes need to help the patients realize that it’s incredibly well to last that long. Like the mouth is a hostile environment and you’re constantly battering, you’re chewing, you’re putting forces down it. And it’s actually magic that it lasted all that time in the first place. I sometimes say to my patients, what can you buy today that will still be there in 20 years or 25 years, however long that bridge lasted.

And the tip this dentist gave this communication tip to add to it was this bridge owes us nothing. It’s been there for 25 years and it doesn’t owe us anything. I just love that saying, I just wanted to pass it on to you. So when you next have that failure and the patient looks a bit gutted, just remind them how well it actually did to last that long in such a hostile environment.

This episode will be eligible for 15 minutes of CPD or CE, and I’ll give you the instructions at the end in the outro as always. So let’s join the main episode and I’ll catch you in the outro.  

Main Episode:
Zahid Shaikh, welcome to the Protrusive Dental podcast. Fellow Protruserati wearing your hoodie. I love it. How are you?

[Zahid]
Of course, of course. I’m very well, thank you. Thanks so much for having me on Jaz. It’s been a long time.

[Jaz]
You got this hoodie because of a Porto right? We went to Portugal for the vertical course with Andre Cardoso. And so yours is much more ironed than mine. I saw you wearing it. I had to quickly go to my gym bag and get out this scrunched up version. But for those Spotify and Apple, you won’t know that, obviously. So it’s all good. Just tell us, buddy, where in the world are you?

[Zahid]
So, I’m working and I’m based in Greater London, Essex area, by the border between London and Essex. I’m right on the border and I also work in Essex and Southend. Working in private practice, really enjoying it. And doing general dentistry, mixed bag of all different things. And I love it.

[Jaz]
And I love your dentistry on social media. I love all the educational things that you post. And I love that you joined us in Porto and got to connect with you a little bit more and they get to know you, about your family and stuff. So I know you a little bit now and I wanted to speak to you about immediate dentine sealing today.

[Zahid]
Yes.

[Jaz]
Which is such a huge hot topic in adhesive dentistry. So before we do that, just tell us about a little bit about your journey. Where did you qualify from? And what got you into general dentistry? A lot of people like specialise and stuff, but you seem to be a bit like me. You embrace general dentistry. Now, correct me if I’m wrong. How did that happen?

[Zahid]
So I graduated from the University of Dundee in Scotland. Obviously, I was born and raised in London and I ended up somehow ending up on the other end of the country studying and learning there.

It was a completely different world. Got to learn a whole different way of life, different values, and I absolutely loved it. I still have lots of friends up there. I haven’t been back very much since I graduated, but still got lots of love up there. And so after practice, I went into my foundation training, came back to London for my foundation training.

My plan initially during my undergraduate years was to just go on and do MaxFacs. That was my plan. Finish dentistry, get the best marks that I could, then go and apply for medicine and then do MaxFacs. I did my vocational training year and I absolutely loved general practice. All the bits and pieces, the intricacies, the 0. 5 millimeters of this and that, that I thought was just went way over my head when I was at university.

I fell in love with all of that, like the meticulousness and the artistry. I just love all of that when it comes to dentistry. So general practice allows me to do everything that I wanted to do about working with different people.

Building relationships with my patients and getting to be able to see my work back and work on my failures and get better because I’ve only got where I am today by being ultra critical of my own work. And that’s what I definitely recommend to anyone who really wants to upscale.

[Jaz]
It’s clear to all of us who go on your social media that you’re very reflective practitioner and that that is super, super clear and how you analyze and there’s different photo shots you take and so that is amazingly clear. As a GDP I just want to stress and point out and you probably heard me say this on a podcast before that as GDP is like we have one of the most toughest gigs in the world.

In the world of dentistry, GDP is like, is super tough, right? We all know that sometimes it’s nice to be a specialist and have your tiny little niche, which you’re like an expert in. But as a general dentist, we put a lot of pressure on ourselves. You have to be a jack of all trades and that can be very, very difficult.

But the beauty of being a GDP is the ability and the permission to cherry pick. And so I want to say, go for it guys. If you want to cherry pick, go for it. You’ve earned it, right? You were a general dentist. You don’t have to treat everyone and everything. And if you draw a line somewhere, you’ll be a much happier clinician. Do you echo that as well?

[Zahid]
Yeah, no, for sure. I’m the sort of person and I have that slight competitive edge that I just want to be as good as I can be at everything. But over time, I’ve realized that sometimes it’s just not worth the hassle of trying to take on the difficult case that you know is out with your skill set.

And it’d be better off managed by someone else. And I think as you continue in your career, you realize how to find the red flags in terms of the treatments and as well as the patients. Which are better off being seen by someone else. Really. That’s the great thing about being a general dentist is that we can refer on.

We can, at some point say this is out with my skillset. And someone else is better treating you. Another thing that I really, really like about being a general dentist is that, you’ve got your periodontists, you’ve got your restorative dentist, you’ve got your endodontists, but we are generalists. So we are, we’re a jack of all trades basically. And I think that makes us very special.

[Jaz]
And it’ll prevent by doing the whole cherry picking thing, it’ll prevent these sticky situations that get into and therefore talking of sticky situations. Let’s dive right into immediate dentine sealing. See what I did there? Yeah?

[Zahid]
Yeah.

[Jaz]
So what is IDS as they call it, like, why has it become such a in thing, a buzz thing in dentistry?

[Zahid]
So I would say IDS has become very very widespread and very sort of a hot topic at the moment because adhesive dentistry has exploded in the world I mean when you were an undergraduate when I was an undergraduate we would talk about composite and bonding but everything was very traditional. Everything was very-

[Jaz]
PFM like PFM all the way, right? That was like-

[Zahid]
Yeah, just your conventional cements GIC, Fuji PLUS, Ketac that was it. Like you’d submit your restoration.

[Jaz]
Zinc phosphate. Have you ever used zinc phosphate?

[Zahid]
Yeah.

[Jaz]
Yeah. Until recently I’ve used zinc phosphate. So now I haven’t using phosphate for a few years now, but it’s still part of our training.

[Zahid]
Yeah. Yeah, definitely. I mean, I remember revising zinc phosphate for my restorative exams, PTSD. But yeah, so IDS, which is immediate dentine sealing, is all about protecting freshly cut dentine. So we’ve gone through a period of where enamel is king, enamel bonding is very, very important, but we have to also appreciate that dentine bonding is incredibly important, if not more important than enamel bonding, because a lot of the time when we’re working, especially on posterior teeth, we don’t have a massive amount.

We’ve got more dentine surface area wise than we have enamel to work with. So being able to protect that dentine is really, really important for our restorations. And now that we’re using adhesive restorations. We need to be able to marry up both the dentine, the resin, and the indirect restoration to bring everything together and last long term. So the technique was first published in around 2005.

[Jaz]
Can I just pause you there, Zahid, we go into the history of it, really good point you raised there about we look for enamel, enamel, enamel, but then we’ve got to give some love to dentine, and an interesting lecture I attended some years ago from Professor Avijit Banerjee.

[Zahid]
You go.

[Jaz]
He showed these numbers, but what’s the actual bond strength? And I’m sure you probably got this in talk about later that we can actually achieve to different materials. And enamel is good. We can achieve a good bond strength to enamel. And the main thing is that you can consistently by doing a few simple things.

It’s easy to get high bond strengths to enamel. The fascinating thing I found at the time, and correct me if I’m wrong, is you can actually get a higher bond strength to dentine than you can with enamel. That blew my mind the first time. Wait, wait, is that right? It’s just that it’s less predictable. To reach that all the time, there’s a few nuances.

Obviously, we’re going to touch on that today. How we can get those higher bond strengths. Anything you want to add to that before we talk about the historical perspectives of ideas?

[Zahid]
So I would say that enamel is enamel. It’s an inorganic substance and it’s there and it’s readily available. Whereas dentine, I mean, there are nuances when you can have hyperplastic enamel and things like that. But generally, enamel is enamel. With dentine, you can have discoloured dentine, you can have arrested dentine that filled with bacteria. You can have dentine that’s –

[Jaz]
Sclerosed.

[Zahid]
Sclerosed dentine, arrested caries. You’ve got dentine that’s been affected by amalgam, dentine that’s been sitting there with a root treated tooth, however many years. So you can get a very, and it’s an organic substance as well. And those collagen fibers are king when it comes to dentine bonding. So being able to manipulate and work with them is really, really important for a long lasting strong bond. And I think that’s the key bit here is long lasting bond, but we’ll go through the science and everything.

[Jaz]
Please, let’s start with the history.

[Zahid]
Yeah. So it was first, the technique was published by Pascal Magne and his team in around 2005. And what they found was that the main key thing was that the mean microtensile bond strength of dentine, which had been immediately sealed compared to dentine, which had been sealed at cementation.

So you’ve got dentine that’s been sealed before you take the impression and you’ve got dentine that’s been sealed when you’re about to cement your restoration. And then when we’re talking about microtensile, we’re talking about the stretchability, how much you can stretch or pull on that bond before it breaks.

So it’s all about testing to failure, basically. So a Magne’s group found that dentine that had been immediately sealed after it had been freshly cut, prior to taking an impression, was shown to be microtensile bond strength was found to be about five times greater than dentine that had been sealed at the cementation stage.

So, not only did it improve the microtensile bond strength, but it also showed a variety of other things that we’ll go through as well. But that was the initial first thing.

[Jaz]
That’s significant multiple, isn’t it? Five is a significant multiple.

[Zahid]
Yeah. And yeah, when we’re talking about dentistry, we can have lots of papers which show slight improvements in certain things, but it comes down to what is a clinical relevance and is it clinically significant? And this was massively clinically significant,

[Jaz]
Were you there Zahid at the Dentinal Tubules? I think it was either a year ago, two years ago. Marco Gresnigt’s lecture, were you there at Tubules?

[Zahid]
Unfortunately, I was not, but I know he’s published a PACE paper recently about, I think it was an 11-year review on indirectly, yes, I think it was. Yeah.

[Jaz]
It may well be. But I was blown away, right? Because what he was showing was his audit data, and it looked really sophisticated of him taking all his data, right? And then he was showing about what great results they get with veneers and how long they last. And then I was being a little bit skeptical, like, oh, obviously, Marco, you’re like treating 19-year-olds, Post Orthodontics, like, obviously, your results will be good, high quality enamel, et cetera, et cetera.

And then he was saying the usual stuff, that the more enamel you have, the better, the more dentin You have, the worse. But then, he said, actually, we now can say we have 100 percent success rate. Now, in dentistry, anyone who says 100 percent success rate is, is full of shit, right? Absolutely full of shit.

And I’ve learned this, like I’ve mentors who I respect and love, but then they make this very bold claim. And then I see their failures and I kind of, okay just bite my tongue. But there’s no such thing, but this guy, he was showing this amazing data, obviously a hundred percent at a certain point, and it could be five years, 10 years, whatever it was.

But the thing was the fascinating thing Zahid was that he was showing that when you had a significant amount of dentine or veneers in dentine, the way his group were able to get near, or for him was a hundred percent success rate at a certain time, basically was immediate dentine sealing.

And that for me was like, wow. I mean, I know we do it for onlays and stuff. But for veneers, I don’t tend to do it because usually the veneers I’ve done have been in enamel, right? But when you are in a position, when you’re into dentine, you have no choice. It just shows amazing what you can achieve with the bond strength with immediate dentine sealing, which is what we’re going to unfold into how to do it, how to actually maximize it. I just want to share that with you and the listeners in terms of what Marco Gresnigt was saying at the conference.

[Zahid]
Yeah, no, that is for sure something that a lot of the time, especially when you’ve got a patient who comes in and they’ve got a veneer that’s come off and you’ve got like 15 minutes to stick this thing back on and you’re looking at the tooth and it’s just all dentine and you’re just like, this is just going to fail again.

Usually it’s another dentist patient as well that you see in someone else’s emergency and you sort of have to have that conversation with the patient. But now with the techniques that we have, especially with IDS, we can be a lot more predictable with that. So yeah, we can transfer what we do on the posterior to the interior as well.

I mean, people like Maxim Bellograd as well, who’s amazing. He has lots of videos even on Instagram where he shows. Where if you’ve got like a little bit of dentin exposure, you can just do a little bit of IDS just to seal that area and then continue on with your normal procedure in terms of your provisionalization. So yeah, it’s-

[Jaz]
So what’s the steps, mate? For the younger dentist colleagues, existing students and whatnot, which by the way, as a student, I had no idea about IDS. Is it a good time now to talk about what are the steps? Let’s say you have a huge MOD amalgam in a lower molar. Let’s start from that position. And then what are your steps to dismantle it? And when you get to the immediate dentine sealing bit?

[Zahid]
Sure. So if you’re not sure about whether you’re going full coverage or not. In terms of an overlay, as opposed to an onlay, then you’re going to dismantle the restoration, remove the entire to the restoration.

[Jaz]
Before you even go there now, tell us the difference between, because a lot of people like, what, aren’t they the same thing? What’s the difference between an onlay and an overlay?

[Zahid]
Okay. An onlay is a restoration that covers one or more cusps, but not all the cusps. And an overlay covers all the cusps. I know it’s a bit pedantic, but I think it’s important to know the difference between the two. So yeah.

[Jaz]
So if you’re likely about, you said that also is that, when you go in, don’t be fixated that I’m going to do an overlay. Like I love that you keep it open and so do I is that, okay, I’m going to dismantle and then measure the wall thicknesses, et cetera, et cetera, and decide, is there a cusp I want to keep?

[Zahid]
Yes.

[Jaz]
Or, and sometimes you just know you’re going to lose all the cusps because they’re so thin. You just know from the start, right? And then you just go for it. But other times you want to dismantle first before you commit to the exact type of restoration.

[Zahid]
Yeah. I mean, you don’t want to get to the point where you’ve done your occlusal reduction. And then you realize that there’s at least one or two cusp that you could have maintained, which makes things a lot more difficult when it comes to restoring the tooth, because the first point of doing a partial coverage restoration is that you want to be conservative of the tooth structure, but you’re going to go and hack it away from the beginning.

Then it makes things more difficult. Sometimes, to be honest, it’s easier to manage on overlay preparation, then it comes to an onlay preparation. Because you’ve got see the undercuts, make sure you’ve got no undercuts. Make sure when you’re producing your line angles, everything’s nice and smooth. So it can be a bit more difficult with an onlay as opposed to an overlay.

But if you’re telling your patient that you want to do a more conservative treatment option, Then you should go in with a more conservative mindset from the beginning. So yeah, let’s say so remove the amalgam restoration. Let’s say MOD amalgam. We remove the amalgam restoration We see what’s left. We measure our wall thickness.

I like to use dental calipers to measure and I always tend to measure from the base of the wall, where the wall, the pericervical region. So where the base of the wall is. So if you have very thick tooth structure at the top of the occlusal surface, but you’ve got very thin slither down at the cervical margin, then that’s just going to lead to that.

That cusp is not necessarily protected. A great term that I heard from Pasquale Venuti was to preserve dentine supported enamel. So enamel without dentine support is basically an eggshell. It’s not going to be protected, and it’s not going to last. So I think that’s a really important thing.

[Jaz]
Richard Porter taught me many years ago that unsupported enamel is not your friend. It’s the same thing, right? These are clever people saying clever things. And what I like to do with my calipers is I just used to measure the base. I used to measure the different areas. But now I kind of just look for the thinnest area. What is the thinnest area? And that gives me like, what’s the minimum thickness there? Because that’s where all the stress is going to get absorbed into.

[Zahid]
Exactly, yeah. So yeah, you measure. You do your parameter measurements in terms of, I’m going to reduce this. I’m going to keep this. You find out what you’re going to keep and you’re going to reduce. Then you reduce those areas, do your occlusal reduction, and then-

[Jaz]
How much we talking mate? Cause I like to ask my nitty gritty details. Like how much are you, how much is Zahid doing in 2024?

[Zahid]
For me, it’s dependent on the burs that I use. So I’ve got these Komet burs that are measured at one millimeter depths each way. I usually go down one millimeter and then for my occlusal reduction, at least for my cusp reduction when I put my depth screws in, but I know I’m going to reduce a little bit further before I then do my IDS and everything.

So it evens out to about between one and 1. 5, but I aim ideally 1. 5. I also have depth gauge burs from Komet, which I use. I just run through at 1. 5 millimeter depths. But yeah, I would say anywhere between 1 to 1. 5 mils.

[Jaz]
You’re more conservative than me. I go for 1. 5 to 2, but that’s cool, man. Honestly, as long as we’re on enamel, we’ve got, yeah, it’s all good. And I know there’s a range out there. So just, yeah, we have a different compass, but you know, it’s half a millimeter here and there. I think we can both agree with that. Minimum 1. 5 is a good place to be.

[Zahid]
Yeah. I mean, it’s funny because I’ve had this conversation with people before. And it’s like, where do you get that figure from? What is that? How do you decide what should be preserved and what should be reduced?

[Jaz]
Jason Smithson told me, and I believed him and I’m going to do it.

[Zahid]
Yeah. I mean, there’s, Dietschi has been, and Magne have been quoted in papers saying this is what is recommended. But there’s no evidence base necessarily behind that specific measurement, but yeah, so you’ve done your occlusal reduction, you’ve removed your restoration, removed your caries, you’ve done your structural analysis about how much tissue structure is left. Then we’re going on to do our immediate dentine sealing. So in terms of how we’re going to do that, ideally, so-

[Jaz]
Before we get here, just for the young colleagues out here, before we get to meet an incident, like you removed all your caries, right? Yes. Everything is all the stains, caries, everything, it’s all nude, it’s all clean, it’s laid bare.

[Zahid]
So yeah, everything is nice and clean. Or even, okay, let’s say we’ve just done our caries removal. Okay, so we’ve used our slow speed bur, we’ve removed all the caries, everything at the ADJ is clear. For me, I do partial caries removal as much as possible. Anywhere where I’m getting closer to the pulp and it’s a softer dentine, then I’ll scoop that out with an excavator. Obviously, you can also use your caries detector dyes as well. I haven’t converted yet, but I know you have. Maybe you can convince me.

[Jaz]
Love it, but Zahid, you totally need to get on it, man.

[Zahid]
And so once we’re at that point, then. Before I’ve done anything, even before I’ve done the analysis of the tooth, I would isolate the situation. So if I know that I can isolate prior to preparation, and I know that when I finish my preparation under isolation, so under rubber dam, if I know that I can do that then, then I know I can isolate when it comes to cementation as well. Because I know I’ve already done it at that stage. Whereas sometimes you end up preparing.

[Jaz]
Exactly, exactly. So colleagues will message me saying, oh Jaz, I prepped for an onlay and then at the fit appointment I really struggled to get dam on. I was running 45 minutes late and what do you do? And the simple question, just like you said now Zahid, is did you prep on the dam? No, I didn’t prep on the dam.

Well, there’s a problem. If you just like you’re coming on to now, if you can prep on the dam, you know that actually this is the correct type of restoration. And perhaps you don’t need something that will probably expand on our deep margin elevation. Maybe we don’t want to get into that because there’s so much to ideas to cover, but let’s have the scenario whereby we can isolate, we can see the enamel.

We don’t need this deep margin elevation, and we’re going to choose to do the ideas, which I think we’re going to agree that we should routinely do this.

[Zahid]
Yes, yes, I would say so. So, yeah. So rubber dam isolation. And then fast forward, we’ve done our caries removal and we’re ready to do our IDS. So I would then do air abrasion.

I have an AquaCare unit and that’s with 27 micron. Oh, I’m very lucky. I’m very lucky. I had the AquaCare before, the old one, and that packed out. So thankfully, my practice bought me the AquaCare I was very thankful. I’m blessed.

[Jaz]
How much, look, I know you use it a lot, right? And just talk to me here, man. How much is the monthly ongoing cost? Because I’m a big fan of associates buying their own stuff, right? I totally do that. I bought my own T scan for Christ’s sake, right? So I’m not afraid to spend, splash the cash. If the practice is going to be continuing to buy the consumables, what figure should I give my practice principal? Okay, I’ll buy it, but can you pitch in with this monthly cost to actually buy the powders? Have you got an idea of that for me?

[Zahid]
I think so. There’s not only the powders, but there’s also the servicing costs as well. I don’t know specifically what the AquaCare unit servicing cost is, but I know for the old AquaCare, It was at least five to six hundred pound a year and then if you need any repairs or anything like that and they’ll charge you their fee to come and fix the unit as well So there’s that.

[Jaz]
But how often are you replacing those pots? Yeah, the actual powder pots.

[Zahid]
Initially you can buy a set of pots that come together and I would say maybe I get through one pot, let’s say three to four weeks, but I use it for-

[Jaz]
How much you’re talking, man?

[Zahid]
I can’t give you, I can’t give you a figure off the top of my head, but it’s not cheap.

[Jaz]
I’m going to find out and I’m going to interject here and I’m going to say, okay, this is how much it costs, which is totally just good to know, man. Cause I’m collecting this data so I can present it, it’s like, okay, this is the running cost every month. Can you sort me out?

Interjection:
Hey guys, it’s Jaz here, just interjecting here with this important message about air abrasion. I just want to say that this is so, so, so important to the extent that I once said that I would never accept an associate position if the practice didn’t have an air abrasion unit. And you’ve heard me bang on about this in many different episodes.

So if you’re still not using air abrasion in 2024 and you want to do good adhesive dentistry, then please do yourself a favor. Speak to your principal, speak to a person who’s got the purchasing power and really try your best to convince them. And if you can’t convince them, dare I say it, buy one yourself.

Like I know Aquacare costs a lot. It’s amazing. And there’s maintenance costs, but a good air abrasion unit costs anywhere from I’m going to say in dollars, maybe 400 to 800. And then in UK 300 to 600 pounds. Just use any, just get one that’s compatible with your chair, with your unit. Maybe all you needed was this little kick from me, this little message for me to go ahead and do it. Air abrasion is crucially important. So please, Protruserati, let’s start if we’re not already.

[Zahid]
But I mean, I use it for everything. Like, I’ll use it for my direct restorations, indirect restorations, even if I need to clean something out quickly just to have a look at it. If I’m assessing for cracks, I can even use it if I’m re cementing restorations, I’ll clean the fit surface with that. If I can’t be bothered to go downstairs and use the lab air abrasion unit, then I’ll just use the one in the surgery.

[Jaz]
That’s why you’re getting through every three to four weeks, that’s what it is. Anyway, I stopped you, you were going to do either way, whether you have AquaCare, like whether you’re like lucky and posh like Zahid, or you have what I have is like a Ronvig whatever, how essential is the air abrasion because of a lot of the Protruserati, it’s one of the most common things that get message, hey, I don’t have this, or my principal won’t buy it For me, I would say that just buy a three, 400 pound five and a buck one. Just get one. So good. But if you don’t have one, do you think it’s still worth doing IDS and continuing from here?

[Zahid]
So there are other methods to clean the dentine other than using IDS. You can also use a pumice paste with like a bristle brush on a slow speed. To clean up the tissue-

[Jaz]
To clean without air abrasion. You mean you meant clean without air abrasion.

[Zahid]
Yes. Clean without abrasion. Other ways to clean the dentine without using air abrasion. So if you don’t have an air abrasion unit, then you can use pumice paste or you can roughen the surface of the dentine with a coarse bur at low speed. Okay. That also comes in, it’s-

[Jaz]
To have other options.

[Zahid]
Later on down the line if necessary. Yeah. If your air abrasion unit packs in and you’ve got a restoration to cement, what are you going to do?

How are you going to clean your ID slip? But yeah, so there are other alternatives. But I would say when it comes to, I’m sure you’ve seen from, I know you’ve mentioned it as well from my work that I post on Instagram, that I want everything to be as clean as possible. Like, I don’t want bits and pieces of amalgam and this and that here and there.

[Jaz]
#BelieveInClean.

[Zahid]
So yeah, I think the air abrasion is really important to keep everything clean, but okay. So after air abrasion, then we’re doing our etching. So Pascal Magne, in terms of how he portrayed IDS is all about the complete etch, as opposed to a selective etch. So etching both your dentine and your enamel.

And obviously there’s different nuances to that as well. With different systems, if you’ve got your self-etching primers, then you don’t have to etch the dentine, you can just etch the enamel. I prefer to do, make sure I do things robustly, so I do complete etch. And I also like to scrub or agitate my etch on the tooth structure.

To make sure it’s got on everywhere I need it to get to and I’ve not left any voids underneath with I’m just sort of whacking it in into the cavity and then you rinse and you don’t want to over dry you can also use your suction to dry instead of using your three in one air because you can cause the collagen fibers to collapse as well.

But if you imagine it’s like the way I like to think of exposed dentine is almost like when you get a scab when you cut yourself or you have a burn and you’ve got that exposed layer of skin. It’s going to ooze and get sticky, and then eventually form a scab. And that’s what exposed dentine is like.

You’ve got your MMPs which will come up and interfere with your bond strength and all this sort of stuff. So you have to think of it as a living substance, it’s not enamel. It just looks like a block of orange or brown or yellow to you, but it is a living substance and you have to take care and protect it.

[Jaz]
I like that. I like that analogy. But I just want to stop you there, but am I naughty? Am I naughty if I am using something like something that’s supposedly quite antibiomimetic? I’m using the G-Premio BOND, 7th or 8th generation. It’s basically an all-in-one bottle, right? It’s my self-etching. Am I naughty if I do that? And perhaps people, the purists would argue that if I’m doing it that way and I’m deviating away from the protocols that show that you get five times more bond strength, for example, or five times more microtensile strength, for example, then perhaps I’m not reaching the full potential.

And that’s probably where I sit. I think that’s probably the case basically until the data proves it. But for convenience sake, which is why I’m doing, I’m using G-Premio BOND. I’m not etching my dentine because that would be the wrong thing to do with that type of bond. What advice do you have for those of us who do selective etching and don’t etch the dentine?

[Zahid]
So with the new technology of their bonding agents that have come out these days, there is still an advantage, but we’ll cut, we’ll sort of come onto this a little bit later, but it’s a concept of reinforced immediate dentine sealing. So you can use your universal bond over the dentine, but also we’re not at this point, we’re not etching enamel.

If we’re talking about direct restorations and we’re bonding to enamel and dentine at the same time, applying our bond to both. And when we’re doing IDS, we’re just working in dentine only.

[Jaz]
Yep. So for me, at that stage, I am just putting my G-Premio BOND on the dentine only. I haven’t etched the enamel and you’re totally right. But which bond are you using? Because you said you’ve agitated the etch and whatnot. What bonding system, adhesive system are you using?

[Zahid]
I am using OptiBond FL.

[Jaz]
Of course you are, mate. Of course, you are. Three steps, the gold standard.

[Zahid]
Yes, yes. I mean, I used to use there’s like a two-bottle system for the OptiBond. It’s called OptiBond Solo. I was using that. But I mean, I am also lazy when it comes to direct restorations. I will use the OptiBond Solo, the tube, but the one bottle system for both. But when it comes to indirect restorations, I’m not going to mess about. And I will use the OptiBond FL. I just find it so much more, obviously it takes longer and you need to be more meticulous with it, but I find you can have so much more confidence in what you’re doing if you can see exactly what you’re doing.

So that when you drop that, when you put that little drop of the primer onto your dentine and you just see it just dissipate over the dentine surface, you can just imagine in your mind’s eye that that solvent penetrating in between those collagen fibers into the dentinal tubules. And then you know that you’re ready for when you then go in with your adhesive, that that’s all going to seal off beautifully.

But obviously if you want to be efficient and you don’t want to book an hour and 15 minutes or an hour and a half for a preparation appointment, then you’re going to use your single bottle adhesive. But the good thing about that is that if you use OptiBond FL, the adhesive itself that comes with it has a sufficient film thickness that you don’t have to worry about that being lost when you come to cleaning your preparation prior to cementation at the cementation appointment.

[Jaz]
Which we’ll come to in terms of temporization, we’ll come to that and that’s very important. So what you’re trying to say is basically, once you’ve etched, you’ve done the primer. You’ve done the adhesive. The adhesive is like, it’s partially filled in OptiBond FL, isn’t it? That’s what they call it. It’s partially filled.

[Zahid]
Yeah. It’s a filled resin.

[Jaz] And therefore it almost looks like you just put flowable on it, right? It looks like reinforced; it looks stronger. It looks like a way, when I put my G-Premio BOND, that’s got a four-micron thickness or something, right? That’s nothing. Whereas you’re dealing with something that’s much thicker and stronger.

[Zahid]
Yes, exactly. So let’s say if we’re going with the G-Premio BOND route. You’ve done that, you’ve cured that now, then that film thickness is too thin for it to last when it comes to cementation because you have to clean that surface again and you’re at risk of cleaning that off.

Not only that, because the film thickness is so thin. There’s a risk that that layer has not been bonded because of the oxygen inhibition layer. So that whole film thickness could not be cured because of the oxygen in the environment around it. But obviously we’ll come on to using glycerin and liquid soap and other options.

[Jaz]
We’ll talk about, we’ll mention why, please don’t use liquid soap because he said that. There’s a reason why he mentioned liquid soap because there’s a question that’s Protruserati sent in. But anyway, let’s keep on track here. We talked about using OptiBond FL in your case or G-Premio BOND in my case. Now with you having done the etch, prime and the OptiBond FL, the bond actually, which is partially filled at that point, are you done with your ideas in terms of actual, at that appointment?

[Zahid]
So at that point I will assess and see if I’m happy with the general film thickness of the adhesive. So sometimes I will go back again after I’ve cured that layer of the adhesive and add more adhesive on to get a thicker film thickness in certain areas.

I just feel like having a thick, there’s not an actual, as far as I’m aware, there’s not a specific thickness that we’re looking for. The reason why that is, is because if we’re using G-Premio BOND, so you can use your OptiBond FL and adhesive and it’s fine as long as you’ve got that on the tooth, it’s not a problem.

OptiBond, the adhesive is generally quite thick, so you don’t have to worry about it. Not going into specific areas or being too thin because of the way it’s formed. Whereas if you’re using something like G-Premio BOND, then you need to reinforce that with a flow composite, which is the next stage. If you want to be-

[Jaz]
Which is what I do. And then what I aim for in that, only because I saw our good friend, Alan Burgin mentioned this on social as well. And he’s very well read up guy. I respect him a lot. It’s half a millimeter. So when I’m doing, obviously like what I’m doing with my flowable to reinforce that G-Premio BOND is killing two birds with one stone.

Yes, I’m doing my IDS. But I’m also blocking the undercuts, right? Which is a beautiful thing, and then you go back and polish it away. So, I love, IDS just makes so much sense to me, because you’re also getting rid of the undercuts. And so what I’m doing is, I’m using G-ænial, actually, injectable, because it marries so well with G-Premio BOND, and it just holds its shape so beautifully.

And, like, for me, as long as it’s a minimum half a mil thickness, but then in some areas it’s going to be more, because I’m trying to block the undercuts. And then I go back and I sort of, polish it back, get rid of any sharp bits, which I’m going to ask you, is that something that you do as well? If you get any sort of sharp spikes of the flowable, in your case, the adhesive, is that part of your protocol as well?

[Zahid]
So 0.5 mil is a good parameter when it comes to the thickness of your IDS layer or the thickness of your hybrid layer, which you’re creating, and you can use just your BPE probe just, to measure that as you’re going around. Now, if you’re using G-ænial, universal injectable, then because it holds its shape so well, you will end up with little spikes and little areas.

[Jaz]
Spiky areas.

[Zahid]
Yes. And especially with our Emax restorations, we want everything to be beautifully smooth. So when it comes to using OptiBond FL, everything sort of evens out and you don’t have to worry about that so much. Another thing I like to use as well. It’s a bit counterintuitive for what it’s used for, but in my daily practice, I use SDR, bulk fill flowable.

And I use that almost as if like a resin coat to place over the IDS layer. And it is self leveling, but basically what that means, it just runs and flows everywhere. So when you place that and you just, I scribe it around uncured over the tooth surface. And then it will just flow and become flat on its own.

Then I don’t have to worry about any inaccuracies or any rough sharp edges. But even then still, once that layer is done, then we’re looking at smoothing things down, like, especially if you’re using G-ænial, then I’ll go back and I’ll use like a small coarse, soflex disc at very low speed, and then just run that over just to smooth off any rough edges.

You can also use like a fine diamond rugby ball bur just to smooth off those areas as well, and just to remove any sharp edges as best as you can. But my preference is to use the soflex discs and then just, just run it very gently over the surface.

[Jaz]
But once you’ve done your OptiBond FL adhesive, what are you then using to get rid of any, eliminate any undercuts? Is it the SDR that you’re relying on at that stage?

[Zahid]
So no, that’s when I would use a paste composite. So just any paste composite, Venus, I use Venus or I use Tokuyama in practice and that’s what I would use. But I would use G-ænial as well. And I would use that. The problem with me is that I stare at my models when they come back from the lab and I see all these little bumps and little areas and that really annoys me.

And I want everything to be as smooth as possible. So when I’m placing, if I’m using G-ænial injectable, I know that this is going to be a problem when it comes to me looking at the model when it comes back, because there may be areas that are, I’m there like just scribing it, trying to get it flat, but I know it’s not going to get flat.

So yeah, that’s why I prefer to use paste composite because I can place it, I can blend it with a paintbrush. Remove the excess and then I can just polish that back, with a soflex disc.

[Jaz]
How important is it to, once you’ve done the, the IDS to go onto, it’s probably something you just about touch on next, but to go ahead and with your SDR, for example. You might’ve got some on the enamel. So, as part of the protocol, how imperative is it to go back and with the type of bur and just remove any of the bonding system that you might have got the enamel.

[Zahid]
Yes. So I use some point to my loupes. I use the same ones.

[Jaz]
I do, but now I just love my five so much that my set. So I’ve got three pairs of loupes now, right? So I’ve got my five, right? And I’ve got the backup of the five in case my five messes up and the backup of the backup of the five in case the second one, while the first one’s being fixed, it messes up. I can’t do dentistry without loops. It’d be a day off work if I didn’t have my loupes. So that’s why I went crazy.

[Zahid]
Fair enough. Fair enough. I’ve still got my old 3. 5s which I’ve not thrown away just in case something happened. But, I tried to-

[Jaz]
You know what’s going to happen on Monday, right? You’re going to drop them. You know it’s going to happen, right?

[Zahid]
Oh, God. But yeah, so, no matter how well I try, I cannot stop that adhesive. Or even the primr, whatever, from getting onto the enamel as much as I try. But obviously you don’t then want to end up in a situation where you’re short of the enamel and you’ve got exposed dentine, which hasn’t been covered either. So it’s probably better to go over because you have to then go back and refine your enamel margins.

That’s partly important to remove any adhesive that may be on that surface, but it’s also important to help prevent your provisional restorations from bonding. In the nightmare scenario to your preparation, but yeah, so that’s where we’re at.

[Jaz] So what are you using? Cause I tend to use yellow rugby ball and sometimes white stones if it’s like a minimal amount, because obviously if it’s just the G-Premio that’s gone the enamel, I’m good with the white stone.

Right. But if I’ve managed to get some of that my G-ænial injectable on the enamel, then I’m going to be using my yellow stone. Anything that you like to use?

[Zahid]
Yeah, so I like to use, so I’ve got an indirect preparation kit from Komet and they have, I’ve probably blunted all the burs in that kit. I’ve only just got a new one and I use the same kit for everything, but yeah, so it’s got like a flame shape, fine diamond, a red stripe. And I just run that over, especially in the interproximal areas, I just run that at low speed with an electric handpiece. Yeah, just very slowly, just the nurse has got the suction in the area, but I’m using it without water.

And I’m just like very slowly and gently just running over those margins, just removing any adhesive that’s there and just trying my best to get a nice flowing margin all the way around my enamel. I’ll also use the coarse soflex disc for that as well, the small one. And I’ll also use the rugby balls on any areas where I want to bevel my margins, like on the buccal, on the buccal aspect to try and help blend the restoration into the preparation.

Palatally, usually. I’m just doing like a butt finish. And then I also have, like an end cutting bur. So it’s only like a cylinder and it’s only got diamonds at the base. And I would use that to refine the box as well. But you could also use a white stone, just a white stone that’s been modified to do that as well. And that’s usually what I would do. Yeah.

[Jaz]
At that point, can we now say that once you smoothed it, blocked the undercuts, etc, that we have just performed a successful IDS?

[Zahid]
Yes, I would say we’re there now. We are there.

[Jaz]
But then the issue is, which you allude to already, that if you go ahead and now put your bisacryl material on this, it’s going to stick. And it’s happened to me years ago. It doesn’t happen to me so much anymore. And it’s because I am totally happy for there to be like the composite or my IDS to be completely covered in saliva before I actually put some, I use saliva as my separating agent, if you like. I don’t actually do the glycerin cure. So please, please tell us about the next steps that you do to make sure that your bisacryl doesn’t bind to your IDS.

[Zahid]
So the whole reason why we can stick increments of composite to composite where we’re doing a direct restoration is because of the oxygen inhibition layer. Because the surface of that composite has not set, we can add composite to composite incrementally. And glue composite together. So when we get to the end of our IDS, we’ve got a surface layer of uncured resin, which is sticky. And that sticky surface can then bond to our temporary crown material. If it’s a resin based, acrylic based material and-

[Jaz]
Luxatemp, ProTemp, whatever you’re using. What do you use at the moment?

[Zahid]
So I use a ProTemp or I’ve moved over to Clip now, actually, and that doesn’t seem to stick at all.

[Jaz]
Okay.

[Zahid]
Yeah. Yeah.

[Jaz]
Oh, it doesn’t stick.

[Zahid]
No, no, no. Clip is, I can’t believe I hadn’t used it before, but it’s like especially in the posterior region, you don’t have to worry about it.

[Jaz]
Oh, as in it doesn’t stick to your IDS, you mean?

[Zahid]
Yes, yes. Because it’s quite spongy, you can just pop it back off. But I’d still do the oxygen inhibition layer. Anyway, regardless.

[Jaz]
So CLIP or the other alternative would be Telio by Ivoclar, right? Same stuff, right?

[Zahid]
Yeah.

[Jaz]
So you just, I think CLIP is a VOCO product.

[Zahid]
Yes.

[Jaz]
So you roll it into a ball. You thumb it in. We’ll tell us more about that protocol shortly, but either way, whatever you’re using, because one of the questions we had recently on the app was how do I get more retention from my TELIO? Because these guys are finding that TELIOs are coming off.

So we’ll talk a little bit about that. But anyway. What are you using to get rid of the oxygen inhibition layer so that you don’t get this clip or this Telio or the bisacryl sticking to your IDS?

[Zahid]
So initially I would use glycerin, just normal glycerin that you can get from the pharmacy. There are branded ones which are very, yes, you can get K-Y if you’re fancy like Jaz.

[Jaz]
I’m not fancy. I switched to something called ANAGEL, which is this ultrasound gel. I picked this up from Marketo. Oh gosh, I’m have to get his name. Nice Italian chap. Anyways, cool Italian chap who uses ultrasound gel. So I bought this like big, what I love about this ultrasound gel is like, it’s a big tube.

They can just squeeze. Right. It’s just so good. And then you don’t yet, you avoid that awkward thing about people opening up your drawers and seeing K-Y Jelly patients tasting it and all sorts of funny things that can happen scenarios. So ANAGEL for the win. One of the Protruserati actually message saying, can you use liquid soap?

But he messaged us on the app and he said, can you use liquid soap? I said, you probably could. But in my mind, like, why do you want to produce bubbles and stuff, right? Yeah. And liquid soap probably costs more money than glycerin. I’m thinking, I don’t know. Since COVID maybe, I don’t know.

[Zahid]
I’m sure there’s like, because even after you’ve washed your hands, you’ve got the fragrance that’s left. If you’re using liquid soap, you’ve got all the other things.

[Jaz]
Nice smelling onlay.

[Zahid]
Yeah, yeah, I mean the patient might not like it because it would taste horrible, but yeah. So I was using glycerin But it would I felt it was quite runny and it would just run off while I’m trying to cure the oxygen miscellanea. So that after off your recommendation, I’ll move to ANAGEL and that really holds its shape and form but you can also if you’ve got the rubber dam on and if you don’t have any of that then depending on where it is in the situation.

You just need something that’s see through that light can penetrate through That removes the oxygen from the area. So you can also use water. You can just get your 3 in 1, put the water, make it pool up over your restoration, as long as it doesn’t fall out of the patient’s mouth. And then like you’re through that, that also works as well because-

[Jaz]
Anything that blocks the air would work. But yeah, there’s a reason when people use glycerin and just like you said, the reason I took that recommendation, I moved to an ultrasound gel and ANAGEL is the one that I just experimented on Amazon and it worked well. Please, it’s ANAGEL without the L in the middle. So it’s not analgel, it’s ANAGEL.

People please, people misread that on my post once and they think, what the hell are you using? This is worse than KYJ. It’s not analgel, it’s ANAGEL by the way. Okay, so let’s get that out of the way. So you’ve done your curing with the air block to get rid or cure, this uncured oxygen inhibition layer.

Now we’re ready for how we usually do our templates. Now I’m actually interested in your clip strategy. Tell me about your clip strategy. Like what is your end objective? Are you having it in the bite so you prevent the eruption kind of thing? Are you making sure that it touches the adjacent teeth to prevent tilting? How much do we need basically?

[Zahid]
So I’ve used, and I do rotate between using temporary crown material like ProTemp using Liquid DAM or using CLIP or TELIO. But if we’re talking about CLIP specifically, so, preparation’s done, everything’s ready, impression has been taken, and we’re just temporizing now. So, I find it to be very sticky, and usually you sort of roll it up into a ball, get it onto the prep, and it ends up coming off on your thumb.

So I’ll put a little bit of glycerin, or anagel, on my thumb, on my glove, and then just adapt it onto the occlusal surface. Get it into the interproximal areas as well, but above the gingiva. So you’re helping to lock it into position, so you’re stopping any tilting of the neighboring teeth.

[Jaz]
So you’re kind of getting it over the maximum bulbosity of the adjacent teeth, right? But you’re still preserving that sort of, just most apical gingival bit to allow a TePe to go through.

[Zahid]
Yes, exactly. So once I’ve done that, then I’ll get the patient to bite into their occlusion, and then I’ll cure it, or at least partially cure it from the buccal aspect. To get it cured.

[Jaz]
How about getting them to grind left and right to eliminate the excursive load? Is that something?

[Zahid]
So first thing I would do is to get them to sort of bite in ICP and then cure it. And then if you’re trying to get them to move in excursive movements while it’s still unset, it’s just going to pop off again. It’s just going to come out. Will stick to the lower tooth and come out as well.

So yeah, you’ll get them to bite into ICP, partially cure it, then get them to open again and fully cure it. Then check that first in ICP, see if there’s anything that’s come off as they’ve opened. And just remove any excess and then check them in lateral excursions and remove any interferences that may be preventing them from moving in lateral excursions as well.

But when it comes to, so other techniques that I use as well is like with ProTemp, there you would use, and what something that Pascal Magne also recommends is to put glycerin over the preparation before you pop your ProTemp with your putty, or whatever you’re using, pre op, stent onto the tooth.

[Jaz]
So this is glycerin, and you’re not curing through it, you’re just putting it over as a separating agent, like I use saliva.

[Zahid]
Exactly, like saliva, exactly, exactly.

[Jaz]
Okay.

[Zahid]
Yes, I find the glycerin to be a bit easier to apply into specific areas, especially like undercuts and things like that. But yeah, you can use saliva as well, it’s probably readily available.

[Jaz]
Has to be the patient’s saliva, by the way.

[Zahid]
Hopefully, hopefully. We’re trying to get the patient to lick the tooth that you’ve been working on. It’s not always the easiest thing to do. But, yeah. So then, you get your putty stent, and you put that over the area. Then you take that off when it’s partially, partially set, not fully set. Because you don’t want it to knock into place over the preparation.

Then you need to remove your excess, get everything nicely smooth. And then what I found as well is that sometimes it’s useful to create a little bit of space between, if you’re going to use your, something like TempBond or something like that, that’s going to be of a specific film thickness that may prevent your provisional restoration from fully seating. So you might need to make a little bit of space on the occlusal surface of your,

[Jaz]
The inner surface, the intaglio surface

[Zahid]
The intaglio surface of your temporary restoration. So, there’s film thickness for it to seat and not seat high or prevent it siting correctly. This is also a technique I picked up from Atik Rahman, who mentioned this as well, especially for anterior restorations to create like a little, little hole for your temporary cement to come out or for your anterior restoration, so they fully seat.

Interjection:
It’s Jaz interjecting again. That’s a great little tip there, adjusting the inner surface or the intaglio surface of a crown to give you some space for that temporary cement because sometimes the crown can be so thin that the temporary cement will actually crack it. You must have had that happen to you before when you’re trying to seat a temporary crown, and as you seat it, it’s soaking up so much pressure that it just cracks.

So to have that space for the temporary cement is a good idea. And the name given to the inner surface of the crown is Intaglio. And of course, if you remember from the last episode, Intaglio is the name of this new service that I’m co founding to absolutely revolutionize mentoring in dentistry and all aspects of healthcare.

We’re starting in dentistry, which is finding a mentor and helping the mentors find the mentees. I meet so many great experienced dentists who want to have the opportunity to share their knowledge and share their experience with younger colleagues, but they’re like, where are these guys? I don’t see them.

They’re not here at the study clubs. Where are they? So we want to connect mentors and mentees. So if you are interested in being a mentor or a mentee or both. Check out www. intagliomentoring. com. Never forget that word, intaglio. It’s my favorite word in dentistry. It means the inner surface of a crown or denture, and it sounds like a pasta. What’s not to love?

[Zahid]
So it’s a similar concept, creating space for the excess to come out. Because you don’t want to go through all of that, you’ve temporized the tooth, and then the patient comes back an hour later saying it popped out on its own. Which has happened to me many times. And then other ways to help keep that in place is to just tack cure some flowable composite into the embrasures, so it’s not going to pop out.

But just keep it above the gingival when you’re doing that. And then another technique would, like I said, would be to use liquid dam or those sorts of things. Whereas with that, it’s very easy because you just sort of get it into the interproximal areas, over the surface of the preparation, into the next interproximal area, and cure it.

And that will just lock everything in place, and hold it, hold everything where it needs to be. I guess there is a risk of eruption, but we’re only talking about two weeks, or it shouldn’t be too-

[Jaz]
The overeruption would be from the lower, yes, the lower opposing tooth, upper or lower opposing tooth would be erupting. Because you’ve put the liquid dam on the adjacent teeth, that’s actually stopping your prepped tooth from over erupting. That’s also stopping the teeth from tilting in. But yeah, you’re right, it’s just a couple of weeks. Right. And I’ve seen that technique being used. I guess I would probably be more prone to use it A, if I’m running outta time and B, if it’s a root filled tooth. Do you have the same feelings on that?

[Zahid]
Yeah. No, usually I end up opting for liquid dam if the patients come back because the provisional, the Protemp has popped off. So let me just do this instead, but I find that clip or Telio is a foolproof and very quick way. And because it’s quite spongy, it’s a bit more compliant in the patient’s mouth in that two week period before they come back for the final restoration. And it’s easy to remove as well.

[Jaz]
Well, we’ll talk about removal, but I think Jordan on our Telegram group, he suggested as a tip to one of the Protruserati who said that my clip or my telio is coming off, would be to spot etch the prep a little bit.

Before doing the clip, obviously your experience suggests that in your hands it seems to work well, but I guess that’s something someone could do, maybe five, ten seconds before putting the clip on. It might be a bit more of a bitch to remove at the removal visit, at your fit visit. So how easy, what are you doing to just flick off the clip?

[Zahid]
So usually, so what I would do before is to try and sort of ease it out from all the sides, get it nice and loose, and then pop it off. But I find that, especially at the cementation visit, the thing that can take the longest and that should take the least amount of time is taking off your provisional restoration.

That’s the most stressful part. If you can just quickly take it off, then you’re into your cementation protocol. But that is the limiting factor usually for everything, for me anyway. And it’s the bit that annoys me the most. So let’s say if I’m using liquid dam, then that’s just getting something like Mitchell’s trimmer basically underneath.

And popping it out. If I’m using clip again, I can just get the Mitchell’s or flat plastic or something and pop it out. When it comes to ProTemp or something that’s a bit more, has more coverage, I’ll tend to either use root forceps or artery forceps, and then just pop it on.

[Jaz]
AKA mosquitoes or whatever.

[Zahid]
Exactly, exactly. And then just rock it and then it will just pop off. Because if you’re using-

[Jaz]
That’s usually what I do. And usually, like, I usually, I would have used Duralon or equivalent, like, or Poly-F or Zinc polycarboxylate cement. Is that something you use or you tend to stick to TempBond?

[Zahid]
So I find that TempBond is very easy to remove. Whereas, Duralon can be a bit more difficult to remove when-

[Jaz]
You need a bit more time with your crossline scaler.

[Zahid]
Exactly. Yeah. Yeah. But you know, I use Duralon as well. And I find that’s great too. It just takes a little bit more time. Tempbond is just a bit quicker.

[Jaz]
Perhaps for a patient who is going away or has an important thing to attend to, and therefore it’s a bit more unforgiving scenario, and therefore you want something more robust.

Maybe, because there’s no hard and fast rules. And I love that you have all these things in your armamentarium to use the appropriate scenarios. And I like the fact that you also discuss like little shortcut techniques to improve the efficiency, but you have to choose things, everything by its merit in terms of what’s best for your individual patient for that individual.

[Zahid]
Exactly. Yeah. You can’t have only one way for everything. You have to be able to be flexible when it comes to different scenarios. But yeah, if it’s a patient that is going away for a while, or maybe he’s going on holiday the day after you’ve done the preparation.

Then you want to use something a bit more robust to hold everything in place. So yeah, that’s where I would use Duralon in situations like that. But yeah, so.

[Jaz]
Excellent. And top tips for temporaries in my experience have been to light occlusion in MIP or ICP and then no excursions.

[Zahid]
Yes.

[Jaz]
Why would you want excursions and that, basically? It’s something else. So yeah, you follow that as well. You can use Duralon. You can use Tempbond if you want to. If it’s a less forgiving, if it’s a more forgiving scenario, for example. And the other technique of Clip that you mentioned, I’m very grateful for that. And then if you are struggling with that for some reason, then Jordan, Frank Gait, one of the Protruseratis, he suggested maybe Spot Etching.

I think we’ve covered some bruised bonus there of Temps as well. So when we now come to the fit appointment, I have heard that because we’re doing immediate dentine sealing, It’s so good that you may not need to use local anesthetic.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end. Hey, can you answer this question? The question I have for you is question number four of our CPD quiz, which is what was the final reduction depth that Zahid aims for? Remember, we are slightly different, but Zahid, what was it that he was aiming for? What was it a reduction depth of 0. 5 millimeters. Was it one millimeter?

Was it 1. 5 millimeter? Or was it two millimeters? If you think you can answer this question, then you’re almost there to getting some CPD. Wouldn’t that be so nice? Imagine listening to every episode and by the end of the year, you’ve racked up 40 hours just from the new episode, let alone the library of 250 hours worth of content.

So if you want to start collecting CPD by answering just a simple few questions, you know what to do. You’re going to head to protrusive. app. Obviously, we’re changing everything over. Like next week, so maybe hold off a week if you want, but at some point, it’d be great for you to join because if you’ve made it all the way to the end of the podcast, I’m hoping you’re enjoying this and you’re getting a lot of value from this, and I promise you the community on Protrusive Guidance and the clinical videos and masterclasses, and also we’re launching Sectioning School.

I didn’t even mention that. How could I forget? Sectioning School will be uploaded, so high quality, point of view, 4K clinical videos of me removing several teeth using my through the loop camera.

Of course, watch out for next week’s episode will be part two of this episode and the second one for adhesive month. And the last thing I’m gonna say is your homework. Just watch out for the emails. Okay. So those of you who subscribe to my emails and on the socials, just watch out. This is a big week. We’re doing a lot of hard work behind the scenes of migrating. Once you join Protrusive Guidance, you’ll see how vast it is, how clean it is, and how much hard work went into it.

So we’re just gearing everything up and ready for it. So watch out for the emails in terms of how to seamlessly migrate from the old app to a new one, or just go and jump in straight to a new one, start fresh and all that. But if you are a Protrusive Premium member already, you definitely want to be checking your emails because I’m going to be offsetting the inconvenience of having to change platforms, right?

There’s an inconvenience, even though it’s a massive upgrade, like a huge upgrade, there’s still an inconvenience because there’s change. So there’s a special little something, something in there for you in the emails, if you like to make sure. There’s no hard feelings about this change, yeah? Thanks again, and I’ll catch you same time, same place, next week.