How to use Injectable Composites to Treat Toothwear – PDP081

Jaz’s Introduction: 
This is exactly what I thought when I first came across this technique but you have to understand something. That is not regular old flowable composite and there are some micro details to gaining predictability which is exactly why I’ve got Dr. Kostas Karagiannopoulos Kostas, I’m so sorry if I perverse your surname there. He is a phenomenal dentist based in the UK. He’s a fantastic restorative dentist and he teaches on this technique so who better to talk about this technique than Kostas. He’s going to go through the entire workflow from case assessment to see who is suitable for injection molding composites to how to execute it and some key gems to take away. So, if you were to do it Monday morning, you’re going to gain a lot from this episode.

Protrusive Dental Pearl:
The Protrusive Dental Pearl before we go straight into this really cool episode is the following right? So many of you are placing let’s say Lithium Disilicate onlays, right? The problem is when you get them back from the lab on the model, they fall off really easily or when you put them on the tooth to try it in like there’s no resistance form. There’s a real lack of resistance form on these on layers therefore they just fall over the place. So, if you have a composite core in place.

I’m a big fan of getting the biggest, fattest diamond bur you have which is around or spherical in shape and just sinking in until you get this kind and if those of you watching right now will describe. If you’re listening, it’s like you see like a semi-circle or a half sphere drilled into the composite and what this does is that the ceramic will now have this extension of this half sphere into it so that now it’s less likely to fall off the model and weigh less likely to fall off when you’re trying it in.

Now it’s debatable whether this actually improves the resistance form of the restoration technically anything that opposes your finger removing a crown improves the resistance form so technically it does, but you do it for just convenience really and as long as you’re drilling into core material and you’re not sacrificing healthy tooth structure then i think this is a great little technique tip. So I hope you followed along there. So, use a big fat round bur, sink it into your core and allow your ceramic to extend into that to help your onlays stay on when you’re trying them in. So, let’s join Dr. Kostas and I’ll catch you in the outro guys.

Main Episode:
Kostas Karagiannopoulos, welcome to the Protrusive Dental Podcast. How are you, my friend? I knew and raised I said it correctly, I think?

[Kostas]
You did it very well naturally with an accent as well. Perfect.

[Jaz]
I used to work with a few Greek dentists, so I always made an effort you see. That you are of course Greek right I haven’t complete or I haven’t completely messed that one up, have I?

[Kostas]
As Greek as it gets.

[Jaz]
Okay amazing well listen you’re someone who has been on my radar for a few years now our mutual friend, Ricky told me about you some time ago and what Ricky said, and he’s been on the podcast as well. He did a whole episode on Productivity with a Prosthodontist. Lovely guy and he said some things about you like ‘Jaz you need to speak to Kostas. You have a lot of sorts of similar philosophies.’

And what he admired about you, Kostas and I don’t know if he told this or not. What he admired about you was you’re working in a hospital setting. You’re teaching, you’re performing, you’re also in wet-fingered practice and in Richmond until as well and then as well as that you haven’t fallen into a trap of falling into like a very narrow mindset.

Because he felt as though he saw something in you and the fact that you actually have training from the USA and you do things a little bit more open-mindedly is the best way that he described it. What do you have to say to that and then also for the good listeners can you please introduce yourself?

[Kostas]
Thanks for having me. It’s a kind of a mutual feeling. I’m going to talk about you first before I talk about myself because I kind of bumped into one of your little videos and there’s this expression that we all know it sounds Greek to me and I said, ‘Hang on a second that guy speaks the same language like me. There’s one more person in this planet that kind of speaks Greek.’

So, it’s kind of okay you’ve got an occlusion background, I’m a prosthodontist. I did a lot of training in the US with an anthologist and an educator called Frank Spear. I followed the British society of occlusal studies about 10 years ago doing equilibration on kind of patients.

So I was looking for this kind of terminology, this kind of workflow so I really liked what I heard and only last week I kind of gave a lecture to my students. Here are guys my post grads about selection of splints. And I said you know what, you just need to go online and do that course. I know you’re paying a lot of money for your employment then but go and do that he’s better than me.

[Jaz]
You’re very sweet thank you so much.

[Kostas]
Coming on to me. My name is Kostas, I’m a prosthodontist. I work here at Guys where I’m speaking from at the moment. I’m a consultant in the postgraduate center I look after the training specialist so it’s purely in an educational role. That’s one day a week but otherwise I’m in specialist practice kind of four days a week in Essex and St. Albans.

I do have indeed quite a mixture of things. If somebody told me hey, you’re going to be in practice five six days a week that’s kind of too much this is like teeth are rattling in your head or you’re going to be in hospital full time that is a kind of a different kind of mindset. And I’ve never really had that. So, I like having a bit of a mixture of the two but then again I do all my training and all my CPD  kind of approach.

Now it’s a little bit tricky with Covid but I’ve been all around the world to kind of gather some information. As far as today’s topic, it kind of the inspiration came from teaching people like Ricky about four or five years ago. We have a toothwear clinic here at Guy’s and we treat a lot of it. Erosion, attrition, a lot. We’re doing the full workup of photographs, wax ups, face bows, and when we actually go to treatment which usually is resin composites as a first line of management, we were not using any of this.

So, we were spending quite a few weeks on the diagnosis, on the smile design and then we were going freehand, and I said hang on a second there’s got to be something different than that. Now freehand is difficult to teach, there’s people in this country and other countries which are excellent with this. But it is difficult to teach and it is difficult to execute let alone teach in order of consistency because if you’re doing a big case by the time you hit the canines or the premolars kind of your eyes are fried up. So, I had to think of ways to cheat, replicate, copy paste and I’ve been doing this for five years now and then I’ve kind of used every single way possible. And I’ve kind of narrowed it down to the technique that I use these days and I teach which is the injection molding technique in collaboration with GC.

[Jaz]
Amazing. Well, that’s exactly what the episode is about today, injection molding for composite restorations and the why, the when, the how, the longevity, all these nitty-gritty details which I think as we were discussing before like you always get the classic questions, the same questions over and over again.

It’s time to let it all out and no longer shall people ask you these questions because they will listen to this podcast and they’ll know all the answers. So, I’m going to hit you with the number one like your origin story of why you needed this kind of a way to treat patients, makes sense. Because to go free hand is very technique sensitive, it’s very time consuming. I love the fact that you also mentioned that yes, we get tired it’s true. Our eyes get tired, and the canines are not easy teeth to actually get anatomically correct by the way. So, by time you get to the canines and then things are looking out of place, spot on.

When it came to injectable composites, a lot of dentists who haven’t used this technique before or maybe have never been considered using this technique before will have some natural reservations. They’re thinking wait flowable that’s not strong enough that’s the first thing they could come up with. So, did you have similar reservations or did you have some evidence to go by initially to think that okay this thing we think that this has a future, this has some legs so was it a bit of a punt or was it based on some pre-existing data?

[Kostas]
Good point. Let me start by saying that clinical kind of evidence in terms of peer-reviewed and meta-analysis and systematic reviews are not there, okay? I’ve been kind of looking for them they’re not there. I’m going to be making a clinical study here at Guy’s but that will take a few years to make so there’s quite a bit of in vitro the data which is very promising.

How did my, let’s say flowable journey start? It was about six years ago when I went to Geneva one of my mentors and composers is Didier Dietschi and he has his own composite called Inspiro, a big proportion of which is unflowable so there was six flowable dentins and four enamels and they kind of transformed the way I do things because they have this thixotropic property that you shape it on a marginal ridge and it kind of stays there. So, I said hang on a second, let’s research this.

Now the filler content of his product is 69%, the filler content of G-aenial universal injectable which is the material of choice for me now is 69%. This is actually higher than some of the composite pastes out there. So, I’m not going to say that it is stronger but the myth of flowables are weak is a myth. So, they are hugely kind of reinforced these days but they do have the stereotype that oh I’m going to do my resin coating with this, it’s just going to be as a base of a cavity and it’s going to be a stress breaker and I’m putting this on the incisal edge.

So, I didn’t have the evidence but if I hear to Didier Dietschi telling me that hey I put flowable on my incisal edges that’s pretty good enough evidence for me because he’s been doing it for 35 years. So, I have my own evidence, I’ve been using them for six years and the failures that I have seen are not in my opinion related to the material itself. It’s more down to the technique and ability to bond, an ability to etch the way that you would like. So, the properties of the materials are definitely there. The clinical studies will definitely come very soon they have all already come out for class fives and class twos but nothing in the kind of load-bearing areas.

So, it’s a matter of time before they do. The benefit that you have by using an injectable or a flowable composite is first of all the ability to replicate anatomy are not to be determined by a lab technician they are better than us. And of course the ability to kind of conform to a specific shape determined by a clear stent. So that’s the benefit that you get. You kind of copy paste an already verified design rather than rely on being on a good mood and being consistent between Wednesday afternoon and Monday morning which I cannot be consistent.

[Jaz]
Very well said and those of you watching on the video, Kostas was waving one of the stent examples which I’d love to see. The origin story, going back to your origin story of trying to plan these perhaps a wear cases or full mouth cases and trying to do like an interim period and that’s why you thought okay there’s got to be something quicker than spending hours and hours doing you know paste composite freehand.

Do you see the role of injectable composites as a transition? I mean in honesty all restorations are transitional we know that already I mean you can appreciate that that nothing lasts forever so you know in a way even all these composite veneers we see on Instagram they’re transitional they’re going to need, who knows what’s going to happen three, four years’ time when it’s been you know 10 years since these composites. Are they all going to go to ceramic? Are they going to be recycled composite we don’t know but essentially the question to you is when you do it is your intention that hey if I can get the occlusal scheme set up here this is going to be my definitives for some length of time or are these just long-term provisionals to test the occluding scheme? What is your mindset when you’re placing these reservations?

[Kostas]
I’m a little bit biased. I have two kind of main principles in my head which determine how I approach a case. First of all, the tooth wear cases they’re going to be presenting with 30%, 40%, 50% damage the last thing that I want to do on this teeth is take them down more. So, I want to avoid crowns. So, I’m already leaving this as a last resort. So, my default approach is going to be additive adhesive dentistry. Now the second thing that influences my opinion is that all the studies that have looked at tooth wear, the very cumulative. So, they put all the diseases in one bag, erosion and attrition and it’s like different all right?

Okay sometimes you’re going to have a bit of a grinder, who’s got a bit of reflux and a little bit of both but on many occasions, you’re going to have pure attrition flat as a pancake and pure erosion crate as big as bigger than the moon. So, I’m going to approach the erosive cases purely in additive composite resin. There’s not a single facet in that patient’s mouth even for the pure bruxist, the neurological bruxist let’s say. Yes, I’m going to do a little bit of a build up to crowns because I want to refine my occlusal scheme and the force distribution and my localized kind of group functions in resin rather than in temporary crown material without double charging the patient.

Because I don’t see the point of going for composites and then going for crowns because you kind of double charge somebody. So yes, I do believe a lot in adhesive dentistry. I do consent appropriately for this that hey and this is a long-term kind of measure but like with all composites I mean injectable composites are no different to any composites. They are going to chip, they’re going to stain, they’re going to break, they’re going to look matte and longevity is somewhere in the region of about four to five years. So, nothing different to the normal composites that we do.

Now they are high maintenance and if somebody is not happy with this, they’re going to have to take the hit and have the teeth cut down for onlays or crowns but I want to avoid this as a first line of management.

[Jaz]
I mean I love what you said that because it touches on the whole thing about functional risk right? Like I think Kois talks about and Spear, they talk about you know functional risk. I don’t like that term that much personally because I think it’s parafunctional risk, I don’t think it’s functional risk because the functional teeth shouldn’t be touching at all anyway. That’s the way I see the world but anyway let’s go with the functional risk thing and you’re right I’d much rather confidently treat that erosive case than that purely attritive case it’s just more going on and like you said you have to almost over engineer that attritive case.

So, I see what you say that in terms of when someone’s main etiology of destruction has been purely attritive you know in your mind already that okay this is more of a transition but when it’s purely erosive without as you said any wear facets you might get a longer time there, but it’s still composite at the end of the day. So what I want to know from you now, Kostas is you’ve been doing this five six years are you yet to recycle one of your ones that you’ve placed five years ago how they’re looking now because I see them you know what I admire about you is you’re posting your cases on your social media to instill confidence in dentists and patients using this technique and I’ve seen a few of these follow-ups over some years and including in private practice. So give us an update how is it looking and how much maintenance did it take?

[Kostas]
Yeah, It’s a question that actually patients ask that hey you’re doing a six unit case or an eight unit case and the kind of the minute you tell them that hey this is going to be about five years they think on the anniversary they’re going to find eight bits of composite by the pillow like they’re all going to come out together. So, what I tell them is that no I mean I’m going to come to the annual maintenance but at some point that maintenance becomes so frequent that it’s just better and easier and makes more sense to just go all in instead of getting a handyman just getting the builders.

So on a consent process I let them know that hey we’re doing this additive approach we’re not cutting your teeth but you’re going to have to come once a year and I will need to polish this and when I do your checkup and I’ll take your x-rays, I’m going to take a little bit of a disc so I will find kind of proximal staining and this is twofold. Firstly, because our polishing and our finishing is not as meticulous on the embrasures proximally as it is on the facial and secondly the patient’s oral hygiene, cleaning, flossing or lack of will lead to some staining in there so you’re going to see a little bit of a halo.

Thankfully a little bit of disking and some kind of spiral silicons are good enough to maintain this So, if people know about things they are kind of okay otherwise they can kind of complain so at the beginning maybe my consent process wasn’t great but now I let them know that hey once a year we’re going to do kind of a maintenance kind of thingy it’s going to cost a few hundred pounds and you have to put that into the kind of budget of things. I haven’t had any catastrophic failures and as I said I don’t really blame the material I always blame myself so I’m going to if I get some kind of distal of laterals breaking off. I’m going to blame my occlusal control because we don’t kind of eat and grind from the inside outwards but it’s the opposite. So, I spend a lot of time at least on the attrition patients to check kind of all the eccentric movements. So, if anything I will blame my etching, I will blame my hybridization and I will blame my occlusal control not the material.

So, coming on to the negatives of this injection molding technique it does have some. Now let me start with the contraindications, if you’re making tiny additions, it doesn’t work. Mind you, if you’re making tiny additions freehand it doesn’t work but that’s a different subject you need to have a certain volume and about a millimeter incisally is kind of the cut-off point.

Another contraindication is kind of having black triangles and not adding facially or incisally of it. Like a clear stents like this is not going to help you get in there so you need something like a bioclear or other kind of freehand techniques. So, the main contraindication for injection molding is the single tooth so I’m doing a layered polychromatic buildup with incisal effects and a little bit of opalescence and all of that. Forget it, you got to get your whatever system you use like dentin enamel and go lay it. So, this technique is not here to substitute layers, it’s here to complement it. So, the main indications for injection molding are kind of tooth wear cases, the aesthetically driven patient who has kind of a small teeth and they need a little bit of a smile lift and just aesthetic changes, and these are the kind of main indications.

Now in terms of problems, it is a technique where you kind of placing a composite tape through this stent and you’re injecting the material. The material has the consistency kind of flowable. It’s not running but it’s compressible. It’s like you can squirt it out you don’t need to heat it up let’s say. So, there is a possibility that you’re going to get voids so a good analogy is like you know when you’re making your Protemp or your looks at your crowns, you always have voids you just don’t know that you do. So, there’s always avoid in there. So, I’ve come up with all sorts of ways to minimize or avoid this. So, one in ten cases I will get some a bit of air trapping and then unfortunately that air trapping is going to happen from the vent where you’re injecting from which is incisally so it can lead to a bit of staining or a fracture. So, there are kind of ways to compress this, so the clear stent is made pressurized. It’s not just a bench made kind of stents. It’s made in a hydro flask, in a pressure pod so that it fully polymerizes so the adaptation of this material called Exaclear which is a clear silicon from GC is outstanding. It will even replicate printing lines on the composite made from a digital model. So, there’s no problems with this.

The concept is to have this thick enough it needs to be about a centimeter facially, a centimeter palatally and a centimeter incisally to be rigid enough. So, it basically acts as a stop for the injectable composite. The silicone is compressing the composite so and I’m using this now to compare it to some other techniques which are using restorative paste, heat it up. I believe that if you’re using a restorative composite heat it up to 60-70 degrees or whatever. The paste wants to displace the stent, whereas here the stent is determining the show.

It’s the other way around so there is no way that a flowable composite is going to displace because this is rock solid. I’m trying to kind of bend it back lingually and I can’t.

[Jaz]
Have you thought about, Kostas that with that stent made of exaclear in a pressurized format to supplement it with an Essex retainer on top to or is that just not necessary? Is that something that you’ve tried?

[Kostas]
It is something that I’ve tried. Let me tell you about the alternatives to this technique because I wasn’t the only idiot who had this problem so other people had this kind of issue of like how can we copy paste not going freehand. So back in 2015, the index technique came out from Ricardo Amanato and Federico Ferraris.

It’s basically a kind of the same concept like this but individual teeth. So, you slice up the stent like a sushi roll and you kind of do it on an individual tooth so that you don’t have to mess with the cleanup. So, you clean up each tooth and you go along that works well for mild to moderate tooth wear because you have quite a bit of referencing from the tooth underneath but not for severe wear. So, the Didier Dietschi technique describes exactly what you said. It’s an essix retainer realigned with clear silicon to pick up the detail but the essix gives it the rigidity. So, the problem with this is that you’re kind of having to make holes through two things and you need to kind of drill the holes and that creates a little bit of dust in there.

[Jaz]
Very annoying I usually delegate that to my nurse with a micro brush be like just half an hour just get it clean.

[Kostas]
It’s very annoying so the people that I’ve learned this technique from I mean the person that came up with this technique is Terry Douglas out of the states.

[Jaz]
Hilarious guy and really great with ceramics and material tools.

[Kostas]
So he describes kind of cutting holes with a tungsten bur I just didn’t like the dust because I was leaving it. It was kind of within the matrix and it was looking messy. So what I’m using is the actual tips of the composite you might be able to see the either the vents over here to make an equal kind of diameter hole.

[Jaz]
Hey guys I hope you’re enjoying the podcast so far if you want to download an infographic on step by step like visual aid on how to carry out this technique then go to www.protrusive.co.uk/injection. If you just type in injection it’ll take you straight to the page you need where you can download this infographic and pdf it’s like a visual aid like an aid memoir of all the steps involved. Hope you enjoy and back to Kostas.

[Kostas]
It’s a technique that kind of works but it can have its kind of limitations. It’s designed for mono shades let’s put it this way. It’s not designed for layering so it can allow for layering but it’s a hundred percent mono shade technique which makes it popular for tooth wear cases.

[Jaz]
Makes popular for Essex where you are.
[Kostas]
Yes, so there are different ways to kind of go about it like the essex retainer and stuff but in my personal opinion this is the most rigid. I mean the thickness of this makes it super rigid. So, I have to hold this firmly in place and I need my nurse’s assistant to kind of inject. One problem that it doesn’t solve but it minimizes the cleanup so I’m getting some excess but less I believe than other techniques. So, the equipment that I need to finish a case are a 12 number blade a very sharp curved blade and some ipr proximal strips. I don’t need to use burs or discs. The anatomy is already there for me if I use burs and disc. I’m going to destroy what the lab did.

[Jaz]
Perfect. In my mind, I’m trying to position myself as I’m trying to remember when I used to do this technique and we could talk about some other techniques as well similar to this. And I want to eventually come on to your workflow your one minute workflow like step by step by step because that’s what dentists are hungry for but I’m just remembering some of these times I’ve done it and I used to get sometimes this air void not just where the channel was but in the mesial incisal corner and in the distal incisal the corner. So, then what I started to do was pre-load the stent in the mesial incisal corner and the distal incisal corner and the few times I haven’t got enough cases to be able to say hey this is this works. Is that an issue that you’ve had and basically my question is do you pre-load the stent a little bit as well as injecting from the hole or is it purely injection from the hole only?

[Kostas]
Let me put it this way. If there is any other exit other than the one where the material is coming from, the material will be under compression. It will be within like a lot of hydrostatic pressure. So, I do make sure that there is no kind of escape channels and I will be getting some voids occasionally when I’m retracting the syringe vertically. So, I’ll get some incisal kind of voids but not what you mentioned because I ensure that laterally and gingivally I have stops. I have a frame within, I’m compressing the material. So, I can actually visually see through that stent because it’s completely clear, some of its competitors are not clear so any voids will actually be visible. So I’ve never had it within the material just upon pulling out.

[Jaz]
And you’re purely just injecting? You’re not pre-loading the stent with any-

[Kostas]
No, I don’t. I’ve never seen the need for this. I do like seeing the material being injected and then gradually filling it up as if it’s about to overflow on a glass or whatever so I like it. It’s ever so satisfying saying that but then if you overdo it, you expect some flush. So, the flush management out of all the techniques that I’ve tried is by far the best so you’re going to have a very crisp junction between the composite that you need and the composite which is kind of excess on the cervical and then you put a knife between them and that breaks off.

So, the reason I’m cleaning up this technique is not designed to do multiple teeth together. So, it relies on little blankets, on ptfe tapes and the alternate tooth technique. So, you can either do one tooth at a time but that is quite slow so the fastest you can go is doing 3 teeth together canine central and-

[Jaz]
Other lateral.

[Kostas]
Yeah, the other lateral and then coming back for the other three. So, if these giving you kind of some speed but then again, I’m coming on to the workflow it has more appointments and a higher cost than freehand. So, when I’m pricing things up for my patients it is more costly than freehand because you have multiple appointments, you have a lab fee you have to make stents. So let me now go through how I approach this case somebody comes to me in this case-

[Jaz]
Before we go, I’m so excited for just to you know geek out and tell me your workflow because it reminds me of when I used to do this as well and I probably just haven’t had the cases through to discuss this but also I have recently been moved to a paste system you know let’s just be honest it’s elephant room smile fast.

I have been using smile fast let’s get it out there, okay? I’m Jaz and I use smile fast, okay? Don’t shoot me. So, now that I’ve moved to that kind of system. It has its own challenges, it has its own challenges so I’m sort of experimenting with that at the moment but no doubt I think, I do miss when I did the injectable technique and when I’ve got one or two more cases of smile fast my bet I’ll be able to really then pick and choose between the two different techniques and tell you maybe a few years later which one I prefer but definitely the flush that I found with the smile fast system was a bit but it’s quite quick to manage.

I mean the best thing that you said there were about all the lovely things that I remember using is that every other tooth technique that is a real gem right there and by doing that the downside is that you need two stents right? You need one every other tooth model and stent and one full smile stent and that’s where the higher lab fee comes, have I got that right?

[Kostas]
Well, correct. I mean one way to do it is on the digital workflow you have a six unit wax up, you ask the technician to click the mouse three times and delete the alternate teeth.

[Jaz]
Yeah.

[Kostas]
Then you have like it’s like up and down because one tooth is going to be longer than the other. So, three wax ups have been removed and the other three remain and they make a stent based on that. So, I don’t routinely use this technique I actually just get one made but I create some stoppers for the ones which are not to be bonded. And I do this with my kind of mock-up technique to prevent the injectable from flowing laterally. So, if you’re doing an analog wax up it’s very difficult to remove conventional wax and make a stent for three and then for six. So there are different ways to go about it and after, as I was telling my delegates in the course that I did on Saturday you got to do five cases and in these five cases you’ve done all your mistakes. It is like I’m 100% sure about this. So, there are a few mistakes to be made and the alternate tooth technique works. You can’t do all the teeth together. Other techniques like smile fast are aiming at doing multiple teeth, I am not interested in doing multiple teeth. It might be an excellent technique, but I don’t want to do multiple things. I don’t want to do fast dentistry. So one big benefit in the technique that I do is that I am in control and that comes to the workflow. I am not working with a central lab. The lab that makes my stent is my own lab. It’s no fancy central lab which only works on scans and not alternates and they kind of do one case after the other. So, I don’t rely on any kind of specific brand it’s down to me and my usual lab communication. I mean I WhatsApp my lab technicians all the time regardless now if that’s one more reason.

[Jaz]
He must hate you man. It’s a love-hate relationship. I’m sure.

[Kostas]
My wife might do because I text him more than I text her. But anyway, so, let me let me walk you through my typical case.

[Jaz]
A sequence please do.

[Kostas]
So, William came yesterday, lovely guy. He’s got a little bit of rotation, he’s got a little bit of microdontia. He is not going to benefit from invisalign because he will still need some restorative work. So, he says okay everyone’s talking about composite bonding you’re the man go ahead and do it. So, I will take a full set of photographs, I will take scans of his teeth on my intraoral scanner and I will send all this to the lab prescribing a wax up as if I am going for ceramics. So, this whole concept is basically using the whole build up as if you’re going for crowns or veneers but then in the nick of time you just whoop you kind of turn and you go for composite, so you don’t have to. So, my lab prescription to for the wax up is going to be the following. The first thing that I tell them is that is this an additive wax up or subtracting. If it’s an additive, you can mock it up you’re just adding volume typically 90% of wax ups are going to be purely additive. If you have teeth which are massively rotated and there’s the distal kind of corner is coming out, the lab will need to remove some before they wax. In that case you cannot do an additive mock-up. The second thing that I tell the lab is do they conform to the occlusion or not? So, if it’s an aesthetically driven case it’s going to be an MIP case, ICP whatever you want to call it. If it’s a tooth wear case, they’re going to be opening up the vertical. I will tell them that hey, open up the incisal pin or the virtual incisor pin by two millimeters and separate the posteriors like a DAHL concept, so occlusion, conforming or changing. Then under the aesthetic principles, is the incisal plane correct? Because if you give a dental model to a lab they haven’t got a clue, they need the photographs and especially the portrait pictures. So some information on incisal plane, some information on the midline, typically you’re going to be increasing length and if I don’t want to increase length I will find one tooth which has the correct length and I will tell them hey, use that upper right one to design the smile just like complete dentures nothing.

[Jaz]
Reference tooth.


[Kostas]
Absolutely, then as far as the facial addition which is pretty common thing that people want they want bro the biggest smiles I will kind of give them an indication of where I want them to add and I will take my little kind of pencil on my iPad and I will make some lines and I will send these across. So, basically, I’m giving a lot of information to the lab. The last thing I’m going to ask the lab to do is what stents I want them to make. So, I do not use this clear stent to do a mock-up with.

I make a separate one just putty and wash. Why? Because this is going to get dirty. I don’t want it to get dirty. So, I want it to be super clean for the day of the injectables. So, I’m giving them a long text, a long email which you might think well if I do this in a one of the competitor techniques all I have to do is kind of send them off and they do it for me. Well, I’m a little bit of a control freak. I designed a smile I want to let people know yes the experienced labs will know how to do this for you and if somebody comes out of dental school they might not know how to prescribe kind of these lines and where the midline is counted and all of these things so I want to be in control. So, the lab will then send me a wax up, I prefer a hybrid wax up so it’s a printed model with a handmade wax up on top rather than a fully digital one because the detail that you get on a manual wax than an analog wax in my opinion is better than the one, you’re going to get on digital.

[Jaz]
Purely for the purpose of the of the mock-up right that you’re getting this hand wax up?

[Kostas]
Yeah it is purely for the purpose of the markup but then again nine out of ten mock-ups that I do are fully approved and they become the kind of blueprint for the clear silicon stent so I will rarely modify the wax ups because-

[Jaz]
The Indian in me it can’t resist but say that the lab bill’s increasing here man like if nine out of ten are approving it bite the bullet, go the digital that’s the Indian in me like yeah come on save that lab.

[Kostas]
What do you mean? What’s the benefit of going digital?


[Jaz]
The benefit, because that so the final one where you go to every other tooth model and the full set model. The full set model, the design, the model is all there like he can pretty much send you he doesn’t have to print every other tooth model yet because it’s not been approved yet, but he can just send you that model and make you a putty wash on that for you to transfer into the patient’s mouth. That’s the way I’ve done it because I want to do two wax ups.

[Kostas]
The only limitation of the full digital workflow is that the primary, the secondary anatomy, the tertiary anatomy within the central incisor, the lobes, and the grooves and the perikymata is not as well defined as a well-crafted manually. That’s the only limitation.

[Jaz]
You guys can sense the control freak in Kostas, the attention to detail which is very admirable and you definitely see that shine through social media. So, do check it out.

[Kostas]
But in terms of the workflow you’re absolutely right the digital is kind of the future when the tooth libraries are that good like hyeto’s kind of tooth library from the anteriors. If you use that kind of stuff you can get excellent anatomy but I still prefer like a handmade wax.

[Jaz]
I respect that. I can see why, and I think you’re going for the cutting of the fineness of the fine and that’s awesome.

[Kostas]
So I will then fabricate myself a putty and wash stent as if I’m making temporary crowns. I’ve got a little pressure pot in my clinic so I will make that mock-up stent it looks like this but it’s out of putty and wash and I will use my bis-acryl to make an additive mock-up.

[Jaz]
Your favorite brand bis-acryl is?


[Kostas]
Luxatemp. And I will then scrutinize this, I will take pictures, I will take a video, I will show the patient, I will let them know what they like and what they don’t and as I said nine times out of ten it’s going to be a stunner because the lab is pretty damn good at making this. So, it comes down to the detail on the wax up but the waw-ups are going to be full contour I mean just because it’s a wax up it doesn’t always have to be full contour you’re just filling in corners here and there but basically it’s the art of working out where the teeth need to be just like the Prosthodontic dentures.

[Jaz]
Kostas, can I ask? Is this case mounted on an articulator i.e are you also dahling the function this stage or is it purely esthetic at this stage?

[Kostas]
Well all the MIP cases, the ICP cases they’re going to be kind of relying on the buccal bite of my trios or my scans or whatever. Now if I’m doing any kind of Dahl cases three to three four to four. I will deprogram someone on a leaf gauge and I will take some centric bites with some stone bite or whatever I might have and I’ll keep one kind of centric bite on one side and I will scan the buccal bite on the other side. So that when the virtual models are kind of mounted, they are mounted in CR. So I will not do a face bow I mean the only thing that my lab sometimes do is that they use kind of an interpreter line to kind of do an aesthetic aspect of the face bow. So, I will nevertheless take physical centric bites when I’m changing the occlusion, but I will still kind of scan the mouth the back teeth are apart the OVD is maintained by one century bite on the other side and then swap so I mean.

[Jaz]
That’s a real gem. I just want to highlight that because at times I’ve done that and I’m such a big fan of scanning the occlusion at your desired OVD which is determined aesthetically like I’m just amazed that when I’ve done the injection molding or paste molding or whatever and then I’ve just get them patient to bite together how little adjustments I have found I need to do. Has that been your finding as well?

[Kostas]
100%.

[Jaz]
It’s cheating.
[Kostas]
It’s cheating. I mean you kind of do a big case in ceramics or composites you focus aesthetics, aesthetics, aesthetics, and you’ve got a couple of patients waiting and then you ask the patient to occlude and it’s like a disaster. So, I mean I know that this is going to be very there about so the notion that regardless of how much you open them up it because it’s a kind of a parabolic, you’re going to be at the hinge axis well that’s nonsense because we’re never going to find the hinge axis.

So, you’ve got to be pretty much at the right vertical, two millimeters open which is like the thickness of a occlusal appliance, a b-splint or whatever. So, I will try and do this at the right vertical it’s what percentage of cases are kind of reorganized the small percentage is about 10 percent of the cases that I do.

[Jaz]
In private practice. Because imagine in hospital it’s the other way around.

[Kostas]
Absolutely the other way around. Because in private practice people come requesting this on aesthetic grounds. Now, they may have a little bit of tooth wear but it’s mainly the facial, it’s mainly the looks. So I’m going to get referrals in practice for genuine tooth wear cases, it’s functional cases which needs dahling or a full arch or proper offer because dahl is kind of awful for the poor.

But in hospital, is it’s the other way around so here we have functional tooth wear cases, where the teeth need crown lengthening and more extractions. Just last week, I managed to get the injection molding materials approved through procurement and they’re available at Guy’s. So, we’re going to stop just doing a free hand right, left and center but in practice it’s a small kind of percent of cases which are requiring centric bites, opening up the vertical and things that might be outside of the comfort zone of average GDP.

[Jaz]
Amazing. Is there anything else left in the workflow there so you’ve told us about the design, how to transfer that with the luxatemp to the mouth, you gain your approval. We’ve talked about the different models you make every other tooth; we’ve discussed a little bit about the actual injection molding procedure itself.

The common mistakes which obviously you do in your course, and I think there’s too much because I’m going to wrap up here now. And then anything different, I mean it’s just composite bonding right? So, I don’t imagine there’s too much differences in terms of bonding.

[Kostas]
I mean in terms of longevity studies the technique, there’s nothing special about it. It’s basically about the material so if you do a class to cavity and you put your composite horizontally or in increments it doesn’t really matter. It’s about the material that you use. So, when we have clinical evidence about this technique we’re going to be looking at the injectable composite so on the day of doing the composite, let me make this kind of clear is rubber dam. Rubber dam and injection molding and fighting against each other like they don’t really like each other because this wants referencing points if I’m doing three to three the premolars are acting as reference the palatal tissue and the buccal tissue are acting as reference. So, the few cases that I’ve done with proper rubber dam not split dam or whatever is the thickness of the dam, and the stretchiness of the dam is fighting me. I don’t want anything to fight me so how do I isolate?

I will use my OptraGate I will put retraction cord and I will put my teflon tapes which are going to be tucked into the papilla so that I cannot see the papilla. So, I’m creating a frame gingivally retraction cords and the teflon tapes on the proximal so that I will not have any gingival crevicular fluid, tongues, cheeks. So, the purists might say this is nonsense anything without rubber dam that might be a little bit right. I don’t know yet, but I do know that if I go for the full dam, it’s going to compete with the stents. Now split dam–

[Jaz]
It’s the same for me by the way Kostas with class fives like sometimes it gets in your way rubber dam. So Richard Porter taught me you know eight years ago use rubber dam, always use rubber dam except when it makes your life more difficult and in this case, it’s going to be too fiddly, you’re more likely to make mistakes have the rubber dam stuck in between the stent and the tooth these kind of issues. So, I think it’s actually more predictable without rubber dam in this technique.

[Kostas]
Correct, so for anterior restorative dentistry, it’s of no benefit. Now if you’re doing the wound and tissue and you’re adding on sixes and sevens, that’s a different story. So, you got to have good isolation over there so I’m going to aim for rubber dam and I’m going to trim that stent so that it actually sits accordingly. So, posteriorly you can’t really control. So, on the day of the injectables, I will do my isolation in whatever way. If I’m in doubt about the shading because luxatemp and resin composite, they don’t always kind of talk to each other. So, I might actually do a quick mock-up which is the most expensive mock-up in the world with the actual injectable material. And I will replace my teflon tapes, my nurse will have everything ready she will cut double the number of the teflon tapes that I probably need because they shred, they break and whatever.

Lots of number 12 blades, ipr strips the asap kind of polishers which are like idiot proof and I will not really need discs and burs maybe if I get a little bit of a lip on the cingulum palately with the probe I might feel that something I might put a bird to that. But typically not, so it’s a technique mainly designed for monoshade but the success comes from the communication with the lab. So, the spotlight goes on the GC materials exaclear and the injectable material they are amazing materials and the unsung hero the lab technician who is filling in the bench shaping a wax up having a bit of coffee looking outside doing exactly what I would do if I were to do freehand.

Now, there’s lots of people as I said at the beginning who are excellent at freehand and they teach it very well but I wanted an easy technique and I also want an easy technique to teach which this technique I think is easy to teach. Freehand is not so easy to teach. I like the fact that it improves the relationship with the lab technician, it’s like short-term orthodontics. It’s like it massively improves your relationship with the orthodontist rather than undermining it. And I think there’s a big future for this technique in terms of copying anatomy and okay you might not have incisal effects but most people don’t really look for this anyway.

[Jaz]
Very true Kostas, thanks so much for that absolutely. I’m going to call this a injectable composite masterclass. I’ve never used that word for masterclass. Can’t use master class, as a masterclass. Just give us a real decent juicy flavor of this technique. It’s something that a technique that I actually enjoyed using. When I used it I’ve got a few cases that I’ve put online in the past and I’d look forward to you know using this technique again. Because I’m a big fan of the GC universal flow, the injectable one the gold one is that the one used right?

[Kostas]
Correct. It’s the universal injectable is kind of the that this the sequel to the universal black world. It’s pretty much the same material better salinization and a better tip.


[Jaz]
I just love using that because you know as you said you can actually place it and it will not slump or move and it’s got all the properties you want from flowable but also it’s a highly filled resin, so that’s amazing. Please, please, please, tell us where can we catch your courses? Are they only in England, London, GC where are they? Is there anything that you do abroad because you have quite an international audience here, tell us.

[Kostas]
Yes, I mean I’ve started this collaboration with GC. I love their materials, I love the ethos of the company and I’m going to be doing these hands-on courses in Milton Keynes in their kind of a HQ. And I’ve planned quite a few from now till Christmas. They’re going to be on Saturdays, if you email GC UK they will kind of give you the details.

[Jaz]
Send me that as well any brochure. I’ll stick it on the website. We’ll call this episode protrusive.co.uk/injectioncomposites not injectable because you might spell that wrong. Injection composites and then on their I’m going to have all these details so I want the GC email to get on there any posters that kind of stuff. I mean I saw the feedback on social media recently, it was phenomenal everyone loved it and I can see why. You’re such a great educator.

[Kostas]
If you pay somebody 50 pounds, they’ll say very good things for you.

[Jaz]
Please tell us some more sorry. I stopped you in your tracks.

[Kostas]
But I’m going to be doing some in Ireland, so I’ve planned kind of Cop Dublin and in Belfast for the autumn and it’s kind of going to start, going up north towards kind of Newcastle and Glasgow. So, I would like to do a little bit of a road show because it is a fantastic technique. I don’t want to kind of steal the spotlight as I said is about the technician it’s about the material. So, I do this in collab with GC kind of one Saturday a month and it’s a full kind of a seven-day, seven-hour course like a full day course and I’ve got four hands-on exercises kind of a single central, the peg lateral, six anterior teeth from the alternate technique and then the war indentation four five six and seven.
[Jaz]
So I’m going to I think I’m going to I couldn’t come see your recent cohort because I was teaching in Edinburgh myself actually doing TMD splints for like one hour. So, I couldn’t come to that date but I want to come and see you in Dublin because I really want to go Dublin. I’ve never been in Dublin. So, I’m going to look out for that date. Can you tell us your Instagram handle so we can actually see these cases because they’re brilliant.

[Kostas]
So my Instagram kind of page is @kostas_karagiannopoulos, my surname by the time you get to the first few letters of the surname it should come up because it’s such a ridiculous.

[Jaz]
Good work.

[Kostas]
Name and surname. So, you can drop me a private message on Instagram to ask anything about the courses. I’m always on the other side and I will answer questions rather than tell you no you’ve got to do my course first. So, I’m not that type-

[Jaz]
Kostas have been really approachable I find it easy to speak to him so if you’re any sort of cases, ask opinion, send it to him. It’s been really lovely to connect with you over the last year, Kostas and thank you so much for making time. I know you’re probably looking at the clock thinking oh my god I’ve got to go back to my clinic and my students and stuff. Thank you so much for giving us so much value in this episode, my friend.

[Kostas]
Thank you It’s been a pleasure thank you thanks for having me.

Jaz’s Outro: 
Guys, I hope you enjoyed that episode you should totally check out Dr Kostas’ work on Instagram. He is such a giving clinician he’s one of those people who’s always sharing knowledge and honestly, his occlusion knowledge is up there he’s a clinician I really, really aspire to be like. So I hope you enjoyed that do check out the pdf download once again on /injection and I’ll catch you in the next episode.