Minimal Preparation Veneers – PDP219

Teaser:
So I found after typically seven or eight years, the units were popping off and I wasn’t sure why. It’s gonna feel artificial, it’s gonna feel strange, but I don’t care what it feels like or I get what it looks like because within five or 10 minutes they’ll have adjusted it. It’s how it looks. I mean, originally when we had Feldspathic, you might say, oh, well just use a completely clear feldspathic portion in there.

And that’s where that it sucks in the color from the underlying tooth. Some people are using Feldspathic and have for many years and it’s a great material. But any veneer is gonna, generally, unless it’s a high opacity, is gonna pick up color as long as it’s thin. 

Jaz’s Introduction:
It’s another veneers episode. But with someone who’s got so much experience, 36 years and counting, and a wonderful man. Great dentist, a true GDP, who is pivoted into cosmetic and restorative. The key theme of today’s episode when it comes to veneer is not just the full workflow. I’ve done episodes on that before. And yes, we do go deep into the workflow. It’s a lovely perspective to have, but really the main focus is minimal preparation, the importance of preservation of enamel.

But what about those scenarios where, let’s say you have some aesthetic crown lengthening. You have a gum lift. Am I naughty if I’m now partially bonding this veneer on root dentine or cementum? Are those cases more like to stain in the long run? Well, you see from speaking to Dr. David Bloom, he’s been in one practice for 24 years, so he knows what works and what doesn’t.

And he mentions he’s seen some cases that come back as failures. And what was the reason for that failure? We essentially dissect the Galip Gürel technique. This is a really contemporary and essential way of prepping for veneers. Like when I qualified, I was taught that, okay, for veneers you’ve gotta do like, 0.7 millimeter of prep.

And so in my mind, whatever tooth you have in front of you, you put a 0.7 millimeter margin on all these teeth that is totally wrong. And you’ll see for many reasons why that is wrong and why the Gürel technique is really the way to go. It helps us to give the patient the smile they want, but in the most minimal way.

We don’t go too deep into temporization ’cause we did that in a recent episode with Aidan. So to check out that episode, if you haven’t ready, if you wanna go deep into temporaries, but in this one we talk about the mockup, the planning, and the prep itself. Find out in the end why contact lens veneers are fake news and why you should never do a depth groove at the cervical region.

Hello Protruserati, I’m Jaz Gulati and welcome back to Your Favorite Dental podcast. This episode is totally eligible for CPD or CE credits. You’ll just have to answer the quiz at the end. 

Dental Pearl
The Protrusive Dental Pearl, which I give you in every PDP episode. Gosh, we’ve got hundreds of those. Now I struggle to keep up. Sometimes I get anxiety that I’m repeating a pearl, but it is what it is. And for those of you now listening, I’m examining my hoodie, my Protrusive Hoodie for stains. I went to my mom’s for a curry today. I had some butter chicken, not butter chicken, butter chicken. And I look to have got some on my hoodie.

So, thankfully it’s hidden in the camera, but I can tell you now, the aroma in my office is fantastic. By the way, butter chicken, like is one of my pet peeves. Like Indian people, when they go to Indian restaurants, they always seem to order a butter chicken. It has become, for me, the most like boring vanilla thing that you can get an Indian restaurant.

So my recommendation if you wanna be a bit different like me, is next time you go to a good Indian restaurant. Order the Lamb saag. So this is like a spinach and lamb dish. Much tastier, much richer, much more adventurous, and way less boring than the butter chicken. Anyway, that was a massive digress. I was just coming on to the Protrusive Dental Pearl.

So your patient comes in and they want, let’s say four veneers, upper lateral to lateral, or maybe they want six and there’s a reason why you should never do six, and maybe they want eight, maybe they want 10, you don’t know. But in your wax up, go for 10. Okay? In your wax up, go for 10. Because actually what you’ll do is when you do the mockup i.e., you transfer the putty with the physical into the mouth, and you and the patient assess together how it looks to give the patient an opportunity to see the full smile is so key, because then what you can do is that you can take off the second premolars and the first premolars and the canines and then see, okay, well this is what lateral to lateral looks like.

But we could actually beef out the buccal corridors. Which one do you like better? And this isn’t like a sales technique, it’s actually doing your patients justice. Think of Chandler from friends. Remember his smile? He had these horrible buccal corridors and then he had that corrected. And so by going for this 10 unit approach from the get go, it’s the ultimate level of consent, and more than likely, your patient will probably end up going for it, which is great news because they’ll have a more beautiful, fuller smile at the end.

The downside is it costs more in terms of lab bill, but your patient is paying your lab bill and they’re paying for your time. Again, it’s a theme that we cover with David in this podcast. Hope you enjoy it and I catch you in the outro. 

Main Episode:
Dr. David Bloom, oh, it’s so, so, so lovely to have you on the podcast. Usually, when I see you nowadays, it’s like we both had our drink. We’re outside, hotel somewhere, usually after like BACD or something and it’s always so nice to connect with you. I went to, I dunno if you remember this lecture I attended of yours maybe 10, 11 years ago. Chloe’s Diamond Event. And you talked about veneers. That was my first lecture I attended of yours. Do you remember that? 

[David]
I do remember, yes, absolutely. Yeah. Long time ago. 

[Jaz]
You must have spoken so much. I don’t even know how you remember those events. And then that on that day I walked away just learning about your meticulous process and how important the wax up was as a blueprint, which I’m sure we’ll talk about.

And that was really inspiring. And so it’s so great to have you on today. You are very well known in the UK in terms of high-end cosmetic dentistry. So it’s an absolute pleasure to have you on to talk about something that you are very passionate about, minimally invasive veneers.

Before we delve into that, just for those people who haven’t heard of you, perhaps across the pond and around the world, tell us about yourself, David, how did you venture into cosmetic dentistry? 

[David]
So, I qualified in ’89, so I am 35, 36 years qualified in June. I worked with my father for many years. I’m a GDP and did that for 10 years. And then a certain gentle book called Larry Rosenthal came across to the UK. I started with Larry after I was already 11 years qualified, and a few of us started on his course and that was an eye-opener. And then from there we got onto the AACD ’cause we didn’t have the BACD, but thank goodness we do now.

We spent a lot of time traveling and from the AACD, we started the BACD and that was the whole journey. I’ve learned so much along the way and that lots of what we’re gonna talk about is I am reinventing the wheel because I didn’t develop this, but I’m happy, very happy to share it, and it is a journey and a process and so.

Even when you were talking about closed diamond events, I think we’ve evolved from there now because that was the wax up, but now it’s how you do the wax up and how you use it. 

[Jaz]
And that’s exactly, I wanted to get into as little details and you are very much, I don’t want anyone to think that you are a veneereologist in any way because you are so much more than that. You may not remember this. I came ’cause I did the diploma with Ortho when I came to Shadow Mohammed Almuzian and I remember you were there at the clinic. I was, oh, okay. David, nice to see you. And then you were there and you were doing some lingual ortho at that time. So you’re doing some lingual ortho at the time, and I know you do a fair amount of ortho and tomorrow you got like a full case tomorrow.

So you are a very complete dentist. What would you advise, and this is a little bit off tangent, but what would you advise to young colleagues newly qualified who want to get to this level where they are complete dentist? What advice would you give them nowadays? 

[David]
So I consider myself a cosmetic restorative dentist, but first and foremost, a GDP, so basics. And from there I studied occlusion. I was lucky enough to study with Roy Hixson and BSOS, and that got me started. So the foundational work to be able to add all things to your armamentarium, and I did a lot of, we did, veneereology unfortunately was a bit of a thing 25 years ago, but thank goodness we’ve moved on from that.

We have pre-restorative alignment. Lots of colleagues have been involved with that. And so yes, I’ve learned ortho and it’s continually evolving, but I also was lucky enough to be in the same practice for 24 years. And it’s an eyeopener to see what works in the long term and what doesn’t.

Ortho has been amazing and short term ortho, but we still have our orthodontic colleagues. Then the other thing I would add to that is my Bible, my dental Bible is Schillingberg. So understand how to do old fashioned resistance and retention forms, and we both love verti preps. That makes it a little bit easier, and so the knowledge, the basics, but then the hand skills to be able to get retention on anything and Herodontics is also a bit of a passion of mine. Only because implants are great, but only if we have to. 

[Jaz]
I’m glad you mentioned that. I saw a patient today and we’re gonna be doing a hemi section of a upper left second molar, in a few months time. And the occasional time I get to do it, and touch wood, my case selection has been good enough that ’cause I’m done millions of these, right?

 The cases are, you have to be very, very selective these cases. But it’s great to be able to do such Herodontics actually says good fun. I’m glad you mentioned that. And you definitely are very, very complete from what I’ve seen you, so I’m really thankful for you to even answer those little tangents and give advice about doing the basics. Yes? 

[David]
And one other thing to add, I mean, if we’re talking about  Herodontics . Let’s not forget Lindhe-Nyman bridges. 

[Jaz]
Please explain for our younger colleagues what these bridges are. 

[David]
So, Scandinavian dentist, Lindhe and Nyman 30, 40 years ago, they realized that you could splint terminally mobile teeth together. And I was lucky enough to be mentored by one of my mentors was Hubba Shah, who’s a periodontist, and he believed in it. I have a patient now who has 28 years of a Lindhe-Nyman bridge on teeth that otherwise would’ve been taken out. 

[Jaz]
How many abutment teeth? 

[David]
She was quite a few, but I mean, splinting them helps. But I had my father in, before we knew what we did about implants, I had him on a Lindhe-Nyman bridge on two canines for 18 months. 

[Jaz]
And this was just replacing canines, canine, also like a cantilever to premolars. 

[David]
He had, for many reasons. We kept it going and whilst we transitioned him to implants, we had him on two upper canines on a 10 unit bridge for 18 months.

[Jaz]
So, yeah, I mean, you guys search the Lindhe-Nyman bridges, there’s great data and for those patients who are suitable, this can be a great option. So it can delay implant placement or sometimes even avoid it for many years. So I’m glad you mentioned that. 

[David]
And I believe in all of four. I’ve been doing all-on-four for 20 years, but it’s the last resort is what I’d say. And so. Herodontics and let’s learn in answer to your question, let’s learn how to save teeth whenever we can. 

[Jaz]
Wonderful. And what I love about you, David, is that you talk the talk, you walk the walk in terms, you do it. But then you surpassed the daughter test, right? You have the daughter test and then you have the self test. ‘Cause I was there when, when Tom Sealey was doing your veneers. And so just happened to shadow Tom Sealey that day and seeing his wonderful work. And it was you, the patient that walked in and was, oh my god, it is David Bloom.

And so I, saw the whole process of your veneers being done. So there we are, the  daughter test. Yes. But then it’s a self test. You believe in this protocol and your smile looks great. And I saw, I was very lucky to witness it. 

[David]
Thank you very much. I mean, it’s also, I mean, I’ve treated my mother, my father, my mother-in-law, my father-in-law, my wife. I think we shouldn’t be a afraid of embracing the daughter test as long as we know. We’re doing it responsibly, Jaz. You, you know, you, 

[Jaz]
You say all those things. But that scares me, David, because all the dentists I speak to, all the stories come out when you talk about treating family, right. Treating family and friends is when all the stories come out. I dunno how you do it. 

[David]
Well, I mean, it’s again, like everything, it’s a privilege. But I mean, I treat them like I would any, I make contemp lots of notes when I’m treating my family. Just ’cause it’s a deep. 

[Jaz]
That’s a secret because if you put your guard down and then you become too familiar, that’s when things go wrong.

[David]
Absolutely. So once we put our white coats on, or not our scrubs on, but we used to be a white coat. And I think you’re right actually. And treat everyone the same. And then they are a patient, not a relative. 

[Jaz]
Brilliant. Well, minimally invasive veneers. Okay, so we have so many questions. Like recently, I hosted an Australian chap, Aidan, and we talked about the temporizing element of it.

And so I wanna touch on your protocol, so there’s so many different questions I have for you. I wrote them down and I know you sent me a wonderful summary as well. So guys, there’s so much meat in today’s episode, I have to say. But the first thing when I learned about veneers, and from you as well, is the importance of enamel as like, being a, such a key requisite.

And then you already mentioned actually, in terms of your evolution, right? And what you were taught perhaps in Rosenthal and the kind of preps that were then back in the day compared to now, and how therefore your protocols involved. Tell us about the importance of staying enamel, why that’s important for longevity, for those who don’t know. And then I want you to then bring in the kind of protocol that you use now so that we can remain in enamel the best way possible. 

[David]
So I touched on that, having been in the same practice and starting with what we were all doing, quite aggressive preps, we would offer ortho, but ortho would classically be a year to 18 months.

We didn’t know that we could just do anterior arrangement like we can now. So we used to heavily prepping and it was fine. But what I found was after seven or eight years. These units were popping off. And I mean, I’m a fourth generation bonding guy. I’m OptiBond FL. I was using the same bond then. I don’t think it’s about bond strength, it’s about the enamel and longevity is enamel.

So I found after typically seven or eight years, the units were popping off and I wasn’t sure why. And then we realized that for longevity we need to be an enamel because that is a permanent bond and we all know the water and that’s what it tends to degrade. And I believe in dentine bonding.

I’ve studied with Pascal, we’ve done IDS, so I understand all of that. But if we’re gonna be certainly elective treating the patients, we need to be as minimal as we can for the longevity. And we will talk about a 10 to 15 year lifespan. I think that’s fine. But the purpose of that for me is so that someone understands that it is gonna have a lifespan. It’s gonna fail eventually. But I think bonding to enamel, I’ve got cases that are going 20, 25 years. Because they’re bonded to enamel. 

[Jaz]
And when we want to plan to bond to enamel, there’s the whole concept of no prep. But what you are talking about is minimal prep. So is there a place, firstly of no prep, for example, you just take an impression, take a scan, send the technician, and they literally just send you back some veneers. Does it ever happen that way that you can just do no prep? 

[David]
So first of all, what are they sending back? So I mean, we have to go through our workflow, which first of all is a comprehensive exam. We have our photographs, we have our conversations with our patients. What do they want? All all of that we are taking is a little bit of a given.

But how do we plan to smile? So first of all, it all boils down to smile design. We have to be really very confident. First thing I’ll do is after our social graces and finding out what our patient’s concerns are, is I’ll take my photographs, I’ll take my standard BACD shots, I’ll take my M sound for lips At rest, I’ll take my e sound.

For maximum gingival display, I’ll take a shade picture and that’s all for my diagnostic. So even with a prepless case, I’m going to be giving a diagnostic to the lab ’cause I have done prepless cases. They are rarer than s teeth for for reasons we’ll get onto. But even with that, we need to start with a diagnostic because I would still do what we’re gonna talk about as a visual try.

And so before I touch anybody’s teeth, even with a prepless case, I want to have their buy-in and their understanding of the process. And prepless cases are great, but reality is a veneer generally is half a millimeter thick. Can you add that whole half a millimeter without making things too bulky?

And so the analogy or the patient would come and say, I would like you to do a case without touching my teeth. We’ll do a visual try and if they say they’re too bulky, they’ll understand why I have to prep their teeth. And if they’re not too bulky, then fair enough. So prepless is great. 

[Jaz]
And this is before you even get like an additive wax up. What you are alluding to is doing a chairside mockup in terms of visual trying. Is that what you mean? 

[David]
Absolutely. So the workflow is, does someone to make the changes. We discuss what that is to help them visualize it. And even actually for your routine patients, it’s entirely reasonable to say, well, I’ve got something I’d like to show you because you might have a small and deficient back back of corridor. You might just have some chipping. So yes, I’ll do some mockups, direct mockups, and it’s all about the workflow of helping them move forward. So that would then take them to a wax up. Now a wax up is always gonna be additive.

The question is how much additive and if you want a prepless case, then you are trying to add the whole half a millimeter. Now that might be okay. It might not. Generally speaking, I find that it’s not always okay without making things too bulky. But the real crux is that you can always add 0.2 or 0.3 of a millimeter.

Always. And I’ve been doing this for 20 years, since my eyes were opened when I did a member’s pearl at AACD about visual try, and I was introduced to the idea of an additive wax up. The question you’re asking is how additive can we be? Mm-hmm. And we can’t always add it be additive that 0.5, but we can always be additive that 0.2 or 0.3.

Now we therefore have an opportunity to show the patient, confirm that we’re on the right path, and they understand why some preparation. And therefore, if we’re only prepping 0.2 or 0.3, ’cause we’ve added 0.2 or 0.3, and we’ll talk about how we can be sure we’re doing that. That means we’re a hundred percent enamel. And that’s the only way I think we can really be responsibly prepping teeth. And if we pre align, that’s always possible as well. 

[Jaz]
When you are seeing these patients, first time you’re doing your full photos, full diagnosis, you wanna hear their wishes. And in our sort of pre-chat and the discussion that we’ve had by email.

Like, I don’t want anyone to think that dentists are just going into veneers. You are very much a GDP first. You are stabilizing caries. You made a point about making sure that their periodontal health is good and kind of yes, that is a given in a way, but it’s just worth mentioning because it is a such an important phase of it that not everyone qualifies themselves to have veneers because they don’t show you that they have the commitment. Would you agree with that statement? 

[David]
Absolutely. Health, first we have to do a diagnosis prevention. I’ve worked with a hygienist since I qualified. My father had a hygienist, some well-known hygienists I work with, and it’s a prerequisite health first and elective treatment. Explain to a patient, whatever I do, however well I do it.

It’s gonna have a lifespan and the key is to do as little to your teeth to achieve what you want to achieve as possible. So we all know aligned bleach and bond or aligned bleach. Correct. Whichever. Same thing with just different terminology. Absolutely. Pre alignment. I’d said we do a lot of short term ortho and we can talk about composite veneers as well, but it’s a pathway and sometimes people want more than can be achieved with just aligning bleaching bond, whether that’s a color issue.

So it’s the responsible pathway and giving the patient the options. And my job really is to give a patient the information so they can make the choices that they feel are right for them. However we do that though, we have to do that as a responsible as possible. 

[Jaz]
And when you are speaking to them about their smile, let’s say they are stable now, caries, perio, they are a gold star patient that you wish to go further with because the last thing you wanna do is do your lovely veneers when there’s inflammation, bleeding, et cetera.

So we know that okay, the patients are on board, they’re an, you know, as a, in the perial world, they call it an engaging patient, right? So you have an engaging patient, fine. And you wrote an interesting note to me. You wrote about a permission statement. When you’re communicating, tell me what you mean by a permission statement.

[David]
Well, sometimes, I mean, I’m a GDP, so sometimes now at this stage in my career, I often have people coming to me saying they want to change their smile, which is lovely. But also as a GDP, you see people’s smiles and you know that you can make some changes for them that they don’t know, but you have to ask their permission essentially to say, can I show you what I can see in my mind’s eye?

And obviously we can do Photoshops, we can do imaging, but there’s nothing as powerful as being able to show someone in someone’s mouth. So it’s polite to say, can I show you something that might be of interest? And it might be ’cause you’ve been on a course or you just said something I think you might see.

And that it’s really powerful when they say, oh, I didn’t realize that. And I’m not trying to sell anybody anything, but I’m passionate about having a lovely smile and a cosmetic smile and how can they understand what’s possible if we don’t show them? So I think it’s entirely reasonable to advise people of what’s possible without trying to sell them anything. But if we’re gonna do the work, we have to do it responsibly. 

[Jaz]
I think the great example of that, and I think you’ve spoken about this before, is if someone comes in with the preconceived idea that they need upper two to two, so lateral to lateral for our American colleagues, or canines, canine.

But then once you do the visual mockup, then you can show them, but actually it’s your duty to look after the buccal corridors and show them, because the last thing you want is a patient to complaint in the future. And so that’s when you get their permission so you can show them. And when you do that, do that one side or do you have both sides or they can see a difference left and right.

[David]
Well, so if we’re talking about the workflow, it’s everything is a step to help them move forward. So for a buccal corridor, for example, I probably might not touch three to three. I will just show them widening the buccal corridor. And I mean, classically the number of teeth I like to do is one four or 10.

Six is a bit of a bug bear for me, but almost a much of a bug bear is eight. So people won’t necessarily understand that. But if we wax up 10 and we do a visual try, what you can do is just take off the last two units and suddenly they realize that they have negative space if you don’t do enough teeth.

And similarly, so it’s all an education process and a demonstration process because some people say, well, I want you to do six. I may not choose to, but at least I’ve shown them why I might not. But asking their permission to show them and then the additive wax up and then the visual triad, which is the key, which is before we touch their teeth, we have a putty index of their additive wax up, and we can put that on.

And that allows us to take extra units off. So you can show them 10, you can show them eight, you can show, et cetera. So it’s in- 

[Jaz]
So the trick there is wax up second premolar, second premolar, but then you can always take units off to show them the lateral collateral canine to canine. 

[David]
And especially in the UK where historically we might have had more premolar extractions than we’d presently, like, so a 10 unit would involve premolarizing the sixes, so look like a premolar. And again, it’s not about selling them the extra units, it’s saying what I think would look best. And once they see it, they invariably do. And the power is that you can take off the extra units and allow them to visualize it and everything that, and my journey started with the visual diagnostic try, which is basically a try as we get onto, it’s what Galip started, but we prepped through that. During them see it stage by stage, and therefore they decide and choose the treatment that visually looks best. 

[Jaz]
Tell us about when you are seating. So you’ve got the wax up, you’ve got the putty of it, which brand of bisacryl you’re using, and are you just drying the teeth and loading it up or are there any other tricks that you’ve learned to make the visual try and just pop a little bit more and have a bit more of a gloss, ’cause sometimes the last thing you want is a bisacryl that’s like bubbled and feels really uncomfortable and sharp and annoying. ‘Cause then they’re drawn to that rather than actually what it looks like. 

[David]
Very good point. And I do explain to ’em that it’s gonna feel artificial, it’s gonna feel strange, but I don’t care what it feels like or I get what it looks like because within five or 10 minutes they’ll adjust it. It’s how it looks. 

From there, I think it’s a lot easier now we have digital wax up so we can have really good quality, surface anatomy, which obviously was a lot harder when we were doing that analog. And then a putty index that I would generally say get reline. So there’s ways that you can, there’s a putty with a light body flow.

And then my favorite go-to, and we’re not sponsored by DMG, we should be, they’re a great company. So luxatemp for me, there are many others. And the reason I like luxatemp is that it’s actually got a significant amount of composite in it. So what we’ll talk about is that you can add to it. So part of the skill is I don’t, and I say to a patient, this is our starting point, not our end point.

So we start with vision. So you should be able to re-contour that, know how to re-contour that. That’s a skill that’s essential to learn because they say, well, I don’t like that. And then you say, well, I can make these changes. And suddenly they see that it’s actually a process, not this is how it’s gonna look.

But a good bisacryl, my preferred is luxatemp. Being able to recontour it and then just a glaze. But also pre-warning the patients of what to expect. It’s gonna feel artificial. Like everything. Once they know, they understand, I’m just showing you how it looks. Don’t worry about how it feels ’cause it’s gonna feel very alien.

And then you may not be right, but pre-discussion, do you like open abrasions? Do you live in Essex or Liverpool? And do you want straight white teeth? Which obviously there’s the move for, try not to encourage that. But we talk about shade before and when I do a visual trying, I try not to go for a very bright shade.

I try to go for a natural shade. I want them to see the teeth, not the color. So those are the tips I would suggest. But again, it’s a process and every time you have touch points that help the patient be very involved and medical legally, they can’t really say they didn’t know what they’re letting is or they themselves in for, and probably one of the favorite things I say to a patient, a patient’s gonna say to you, well, what are they gonna look like? And old school dentists will say, trust me, they’re gonna look great. Well, that’s not really want, I’m gonna show you how they’re gonna look. We’re gonna work it out, and then we’re gonna have a lab copy that.

[Jaz]
Lovely. So we’re gonna get into the workflow of this. ‘Cause there’s a lot involved here, but in terms of just going, taking another step back now and decision making, I just wanna know from you and your experience of doing all these units is there comes a point where you’re gonna transition away from a veneer to a crown because of, it is a huge composite, or for whatever reason, can you give us some guidelines of these teeth can be a veneer ’cause they meet this minimum criteria, but actually to get a good, stable, long-term result, I’m gonna have to put a crown in the mix to make sure that this tooth actually will get some longevity and predictability.

[David]
So first of all, I explain to a patient that the fee is per unit, whether it’s a crown, a veneer, or a veneer onlay, however you like to call it. From there, it’s one of my previous mentors, Bill Koic, said, be a thinking dentist. And we all think and solve problems every day. So take out the previous restoration, have a look, do you have the enamel?

Can you do a veneer onlay? And I’ve been doing onlays for 30 years. They’re wonderful. But again, sometimes it’s possibly easier, not easier. Maybe it’s correct to do a full coverage. A zirconia. And as you’ve said on some of the cause, it’s not that much more aggressive. So I think there isn’t a hard and fast cookery rule you can give, but have you got enough enamel? And sometimes a veneer onlays a great preparation, but then sometimes to just do a little bit of palatal preparation, suddenly you’ve got a crown. But again, you’ve gotta be comfortable with your prosthodontist skills to be able to get retention.

So there’s the mix, but I’m happy with any of them. Reverse three quarter crowns really don’t have a base, I don’t think. ‘Cause reality might not be on enamel. But at the same time, do I do slice preps? No, but I’m okay with a slice prep. In certain situations, if we’ve got diastemas, you’ve got pre-existing class threes, you can do a slice prep or you can replace the class three with a a direct composite and keep it more minimal.

So it’s get a feel for what is correct for that patient given the state of their teeth, the preexisting. And if we’re talking about new cases, then obviously it’s much easier. But we live in a real world where people have pre-existing large MOD restorations, they have class three restorations. And so be a thinking dentist.

[Jaz]
So if it’s a small class three, you would just replace the composite and then put your veneer on that? 

[David]
Absolutely. I would want to be on fresh composite, but at the same time I would still like, ideally one restorative margin. And there’s many ways to do it. Mine isn’t just the right way. It’s what you feel comfortable with.

And if I’ve got enamel, I’d rather bond a restoration on, but sometimes you’ve got so little enamel, why are you trying to do things that aren’t necessarily gonna work in the long term? And we have the luxury now that we don’t have to think about PFM, we don’t need that much space. So we can do things that are almost as conservative. So I love traditional resistance and retention and cementation, but I also love bonding. 

[Jaz]
That’s very clear. And I like balance clinicians. I don’t like the idea of I only do verti preps or I only do this. It’s really like you said, being a thinking dentist. So let’s challenge you as a thinking dentist.

Let’s picture a scenario whereby you’ve got, and you mentioned this in email as well, crown lengthening case. Once you do the aesthetic crown lengthening, now you are on a root dentine. Now to actually do some veneers that will finish and bond to root dentine, but then you get to the other benefits of a veneer.

In that scenario, how do you feel about those scenarios and what have you seen in your experience spanning so many years? How do they actually hold up long term? Do they stain more, are they more likely to fail, or do you find that the remainder of the enamel in that tooth actually covers you? 

[David]
Well, I think you just said it, you gave it away and you gave my answer at the end. Thank you for that. I am not anti-dentine bonding. I believe in dentine bonding in dentine. It’s not that we can’t, I think if you have a significant amount of root or cement, some you’re bonding to ’cause you’ve done crown lengthening. Often, it’s not as much root as you think it is, but I think the priority there is you have to have enamel for the rest of it.

And if you are doing, and Galip’s done a lot of work, the structural integrity of the tooth is, if you’ve got then slice preparations. Even though you’re an enamel, that’s when I think you’re more likely to have cervical failures. If you can keep the structural integrity, then I’m very happy to bond to root surface, although it’s probably not as much root surface as we imagine it to be because the rest of it’s enamel.

So once you’ve got a compromised tooth, then I’d be more likely to think full coverage. But a lot of these cases where they are gum lift cases, they’re not restored teeth. So as long as we’re additive, we then predominantly on enamel with a little bit of root service. I’m absolutely fine bonding to that.

But once you then have significant compromises interproximally, they will work and they’ll work for a significant amount of time. But that’s when we see the cervical areas pop off. It looks like a class five. But if that happens, I wouldn’t necessarily rush in to replacing that unit. And one of the things is we can repair porcelain more than we think we can repair with composite.

And I’ve had that because I’ve had cases that are 20 years old. What do you do? And they know that they may need replacing at some point, but I wouldn’t necessarily rush. And if there’s bit pings off, they keep that piece air abrade it, HF, acid etch it, you can bond that on. And I’ve had a number of those repairs that can carry on. So again, be a thinking dentist, but if you’ve got significant amount enamel, I’m okay bonding cervically to root. 

[Jaz]
And just a small one on that, like do you perceive or have you seen objectively those margins on cementum, root dentine, do they stain more? Is that something you’ve observed?

[David]
The staining is not the issue. The issue is that eventually that’s gonna be your weak spot. I’m not even concerned 10 years or less. I mean, I think it’s still worse 10 years, but it’s not the same as bonding to enamel. But you’re still gonna have a very good expectancy, they shouldn’t stain. It’s only that eventually will be the weak spot where you’ll get a failure in your ceramic.

[Jaz]
And are you still putting a little, I mean, we’ll talk about the prep when you prep through and the using the Gürel technique when you prep through the try in. But when you are on the root cementum or the high by the gingiva in those gum lift cases, are you still putting a bit of a little chamfer in there or are you like not touching it ’cause you don’t want to? How are you managing those areas? 

[David]
So my margin generally is always a micro chamfer, which is technically a slightly exaggerated vertiprep, but it’s certainly not a a a J loop chamfer. Those days are gone. So, and we’ll talk about it, but you are talking about root surface, but whether that’s enamel or not, it’s gonna be the same preparation, which is vaguely, you can just about see a vague sculpting line, Equigingival, and that would be the same whether it’s on root surface or on enamel. 

And when we talk about the Gürel technique, and he’s too modest to call it his technique, but it is him, I don’t put a depth cut cervical because a depth cut classically is 0.5 and cervical enamel is about 0.3. So I will put two depth cuts in, but I won’t go cervical. So the preparation will be the same if it’s enamel or if it’s root surface, but it’s a very minimal micro chamfer.

[Jaz]
One thing I really like that Attiq Rahman says about this exact theme, a topic is that he says, we’re not gonna call it a my A source semantics. Let’s not call it a margin. But then what he says is a change in surface texture. And I really like that as a term for someone to understand that actually it is a change in surface texture. And you get to see that actually we’re definitely not making anything resembling a schellenberg chamfer. It is a very, very subtle in that regard. 

[David]
Absolutely. And we’re not reinventing the wheel. When I first qualified, I used to give my father a really hard time because he used to do the knife edge prep, and that’s effectively what we’re doing every time.

And he’s different from BOPT, which I have no issue with, but you’re right. A vertiprep is just a change in direction. And so me, I like the lab to know where the margin is. It’s equigingival, and I have no problem doing prepless veneers. So if we can do a prepless veneer where there’s no margin, why do we have to put a heavy margin on anything else?

[Jaz]
Brilliant. So now let’s talk about the stage whereby. You have got the try in the mouth, you are using your luxatemp. And then you said a wonderful thing whereby, okay, you’re opening up embrasures and I’m being greedy. I wanna learn in terms of exactly what you’re using, because sometimes I find soflex disc there, they can be a little bit aggressive.

So I’ve heard people say, get those metal discs, which then you can make cute little abrasions and widen them as you go along. Well what’s your preferred method to open up abrasions without then taking off too much physical, which isn’t the end of the world ’cause you can add it back a flowable, but how do you work in those sort of delicate margins?

[David]
So soflex are great. I use them a lot. They call them coarse, medium, fine and super fine. I call them one, two, three, four, much easier. I don’t tend to use one a lot. I use two a lot. One and two are cutting two and three and four are polishing. So, and a great tip that a lab ceramic gave me is that when you’re contouring, the embrasures, do it from the palatal.

Because you can round it more. But again, we’ve had a pre-discussion of what sort of look they want, and going to those details is important, but patients will tend to know what look they like. And the top tip I’d give about a- 

[Jaz]
How do you get them to, you come to it now, but how do you get them to communicate that? Because some people will bring in photos of celebrities. There are textbooks with stunning visuals dedicated to this. Do you use any of those aids? 

[David]
I found just having a con, an honest conversation with them. I mean, do you like the look? And we can look at that, but equally well, it’s actually quite easy to open an embrasure or close an embrasure with flowable or with soflex.

I think the soflex don’t use two courses of soflex and always know that if you open it too much, it’s actually quite easy to and flowable and the tops would be spend some time contouring against your teeth, getting a model and just practicing because it actually is probably the simplest bit. But my top tip would be for a visual try and it’s all the workflow.

So we have either a patient that’s come in wanting veneers or a patient that’s preexisting. You’ve seen that you can make some changes. We’ve maybe done some mockups to help them understand that I want to move them forward to the next stage, which is an additive wax up from the additive wax up. We’ll do the visual try.

Now, this is the only time I get a little bit cheeky is that I don’t like to send a patient away with a visual try. ‘Cause the most powerful part of that appointment is to take it off and give them a mirror back. ‘Cause then they really understand what a change it makes for them. And again, it’s not trying to sell anybody anything. It’s te helping them to understand how water change it makes, and it can be massive. So explaining to them that this is the starting point, it’s not the end. We could change the shapes and you could easily say, well, you could open the abrasions on one side or not on the other side.

And let them understand because it’s a very personal thing of how they want their teeth to look. But my top tip and Pascal Magne obviously sends patients away and I think that’s very good. I would rather they bring their significant others to that appointment or- 

[Jaz]
I was just gonna ask about that because the last thing you want is someone to go home and a comment be said, and then therefore they’re back with you. And then you are repeating that work is really important that there’s significant others involved in that sort of discussion. 

[David]
And I’ll also take photos. I put everything on Dropbox, so I’ll share the Dropbox with them. But they understand that it’s a start of the design process that we can have open, we can have close.

You must understand how you can achieve that with soflex. But as it answer your question, maybe a two or two, certainly not a one, but if you do overdo it, you can fill it in. But then it really is powerful when A, they first get the mirror, but B, when you take it off and you give them the mirror back.

And it’s all about helping people to see it visually themselves. ‘Cause looking on a screen, how do you diagnose it? You can have the photos up, you can show other people, but nothing is as powerful as showing them in their mouth. And they won’t understand an open embrasure or a closed embrasure until you show them.

And when you show them, say, well, I like this side, or lots of tips you can do one side, as you said, not the other side, but it’s helping them work out what is visually appealing to them. 

[Jaz]
Over your years of experience, how long are you booking for that appointment now, where the first time you’re gonna do it because, it’ll be a lot more time for someone who’s less experienced. But, just so know when you reach your level of experience and how many units you’ve done, how long is David booking for these? 

[David]
I’m certainly not rushing it. And the reason is that I don’t charge just a lab fee. I incorporate my surgery time for the visual try and appointment. So whether they say yes or no, my time is covered. I’m not trying to sell them anything. So a wax up might be, let’s say it’s 30, 35, 40 pounds a unit. I might be charging 75, 80 pounds a unit. So my time is covered. For four units, I’d probably allow 30 to 40 minutes for 10 units an hour. But we might get the time to touch on the fact that sometimes it might be more, it might be a full mouth.

Generally not more than an hour. But certainly not less than half an hour. And I want to have them have time to have a look at it, get used to it. I’ll take photos on their phone and again, I want to stress, it’s not a sales technique, it’s helping them appreciate what’s possible and the best way to show them that is in their mouth. Then they could decide what they like, what they don’t like and they don’t have to proceed from the wax up. But generally, if you’ve got the diagnostics right, they will do. 

[Jaz]
And at this stage when we can call in additive wax up ’cause we’re trying to stay in enamel and that’s great. But is this wax up at this stage? Does it dial in some of the occlusion, like to make sure the edge to edge is correct, nice and broad to make sure that when they come on to crossover, everything’s respected or would that come in later? 

[David]
So I tell the patients that the wax up, the diagnostic wax up is for them. It’s as much for me as it is for them because I’m working out where we are. I exclusively, can I build in the guidance and. Obviously occlusion is fundamental, but there’s techniques where we can actually enhance the function with our restorative, because we can build in guidance and different conversation. But the hardest part of an equilibration is not removing the CRCO slide is picking up the guidance.

If you’re doing restorative dentistry, sometimes that works very well in our favor, so I am involving that for me, but I’m not necessarily taking them down the complexities. Although if I’ve got a D type personality that needs it, or even I might involve that, but I am using it for myself as a diagnostic.

[Jaz]
Brilliant. So whilst we are doing the embrasures, we’re doing the aesthetics, you are also maybe adding a little bit more to the canine to pick up more guidance. For example, allowing you to lengthen that lateral to check the crossover position to make sure not only does it look good, but you are satisfied that what you’re doing is something that you can actually deliver in that patient’s occlusal scheme.

[David]
Absolutely. So, the diagnostic is for me to check functionally. And when I do the diagnostic, I won’t actually give them a mirror until I’ve checked it functionally and I’ve checked aesthetically I’m happy. However, once I show it to the patient, they may well say, can we tweak this? Can we tweak that?

Absolutely. At that point, I will take a new scan or a new impression so that next time if they proceed, we are one step further on rather than having to make those changes. So I’ll then take a new scan and I’ll mark on the putty, old putty and I’ll get a new putty made. And that will be our starting point, but it’s all part of it and I will get myself comfortable before I’ll give them mirror. But I won’t take photos and scan until we’ve had the opportunity to review it together. 

[Jaz]
That’s a real gem there, because someone who’s new to this could get very excited, put the try in in, show the mirror straight away, but then actually they can’t deliver that because actually the lower canine will be exactly.

And that lateral and then, so you are very right. And that’s a great point that I don’t want people to miss. 

[David]
Thank you. 

[Jaz]
I’m gonna now just pivot to the next appointment where we’re gonna do the Gurel technique. I know we’re moving really fast and there’s so much more to this, but just to give our colleagues an overview.

You mentioned already the Gurel technique. You also mentioned a slice prep, which I want you to explain where that is a bit later. But just describe what the Gurel technique named after Galip Gurel, one of the best dentists in the world in a Turkish dentist. So please don’t think that it’s all about Turkey teeth and Turkey. There are some fantastic dentists in Turkey, Galip being one of them. Tell us about this technique. 

[David]
Well, I was just, I’m very glad you mentioned that, ’cause that is the same, I mean, it’s more about dental tourism than Turkey teeth. and there are some great dentists everywhere in the world. Okay? 

[Jaz]
Absolutely. 

[David]
There’s also places you can go for dental tourism anywhere in the world, but Galip wrote the original book on it, the Art and Science of Laminate Veneers and I explain it to patients and we all have our terminologies for explaining it to patients, but I would say let’s start with the end in mind.

We can add. If we can add, it’s not too bulky, we know that then we don’t have to make the space people think of veneer. You have to prep half a millimeter. Well, you don’t. Okay. If you can add 0.2 or 0.3, you’re already prepping 0.2 or 0.3. But then how do we deliver that correct amount of space? And that is by starting with the end in mind.

And so we’ve done an additive wax up, we’ve done a visual try, we’ve confirmed that it’s not too bulky. We can add that amount and then we would do the same visual trying, but with a guide to where we prepare the teeth. So if we’re starting with the end in mind and we put our bisacryl, our luxatemp on, we know that we’re only making space where we need to.

And that’s the essence of the Gurel technique. The only addition is that we generally be looking at a 0.5 depth cut. I will put the visual trial on which I’m gonna prep through. I will do my incisal edge reduction. And a top tip there is have a conversation about the amount of translucency, because that will guide how much reduction.

But bear in mind that often we’re being additive, so we’re adding length. I mean, how often are we adding length? So incisor reduction is less of a concern than people think it is because when you’re doing your incisor reduction, you’re generally all on bisacryl. But measure the diameter of your bur. That’s how much incisor reduction you are doing straight away.

[Jaz]
If someone wants really a translucent, again, your lengthening teeth. So very often you’re probably not gonna be prepping much incisally anyway. But how much are you looking to give the lab in terms of a wiggle room space for someone who wants ultra realistic, lots of fantasy translucency. 

[David]
I think the minimum is half a millimeter. That’s not gonna give you any space for translucency from there. One to one and a half, possibly even two. But I don’t think there’s that many patients that crave that degree of incisal translucency. But again, there’s publications where you can have that discussion, but the reality is because we’re lengthening you are gonna have the amount of room for fancy pants translucency or not whatever you like.

I think the key there, and we’ll come back to that if we may, but the key first of all is the depth cuts, 0.5, but don’t do it cervically. So I’ll do my incisal edge reduction and then I’ll go a little bit lower for two depth cuts lines. But away from the cervical. 

[Jaz]
But where are horizontal lines going across, like traditionally using, there are those burs, I dunno what the name of those burs are. They’re probably veneer depth cup bur, but they typically got like two or three little bits on ’em. 

[David]
Very good point. I don’t like the triple ones because that is, so I use a single depth cup bur rather than the triple ones. And we can get lost in the nuances, but you have to be aware that the facial plane isn’t flat.

So you’re gonna be aware of the different facial planes. And even the three doesn’t really work because you’d think that’s a flat facial plane. Well, facial planes aren’t like that, so why would you use a three anyway? But my point is I don’t want that third cut because I’m going too cervical. And the other thing that, that it’s important to touch on, ’cause we’re getting onto preparation, is that when you do your incisal edge reduction, we are looking for a facial path of insertion.

So our incisal edge reduction must always be angled away from the palate. Okay. ‘Cause once we go like that, we introduce an undercut and we can’t have a facial path of insertion. The key is that the wax up is guiding us to our end in mind, and that’s guiding the preparation.

Then when we’re doing the preparation, we set incisal edge reduction, but angle that away from the palate. If you angle like this, you can’t have the facial path of insertion. Then we’ll do our depth cuts, and then it’s a question of joining the dots as regards to a slice preparation, because we lose a lot of structure integrity for the tooth, and Galip has shown this. That’s when veneers tend to crack because you lose the tooth rigidity. So out of choice, I’ll do an interproximal finish line, but without breaking the contact. 

[Jaz]
And so slice prep is essentially breaking the contact and just slicing through it, basically. Essentially, that’s the way to describe it. 

[David]
It is. And the times I use a slice prep is if there’s a diastema case. You’re not weakening the tooth if the tooth’s already compromised because it’s got a pre-existing class three. We have to make the judgment call. What’s the quality of the contact? Would we rather? And in that case, we are not weakening the tooth ’cause the tooth’s already weakened. So if I’ve got a virgin tooth, I’m not gonna do a slice prep unless it’s a diastema case.

If there is a structurally compromised tooth already, then I will consider it. But the alternative, as we touched on before, is you can replace the class three, because you are going to weaken the tooth less, but a slice prep can have a place, but only in a tooth that’s pre preexisting restorations or a diastema. Again, you’re thinking that slice is gonna weaken the tooth and we wanna do everything to not compromise that tooth structure any more than we need to. 

[Jaz]
It’s a bit like when you’re working on molars, premolars, when you’re doing your a caries removal, marginal ridges, how important they are. It’s a similar concept in that regard. What about black triangles when you are feeding those tricky black triangle cases? 

[David]
Again, a very good question. I think you have to assess the quality of the contact and when you’ve got a black triangle, Pascal and his brother Michelle have spoken about many wings and there is ways you can get round that, but that’s quite a high level for a ceramic to get to, and so black triangles are probably more inclined to, I don’t then have a problem breaking contacts.

But the key then is that wherever possible keep that path of insertion facial, because when you start to really prep teeth is when you say, well I need a facial path of insertion. That’s when you are heavily prepping. And then- 

[Jaz]
Do you mean when you have a vertical path of insertion, you heavily prepping?

[David]
Yeah, absolutely. But black triangles, you can still hide because if you’ve got a triangle like this, you can have a tooth in front with a long contact point that you can still hide it. And it depends on, obviously, lip line and assessing. Do you think a dentist and seeing is this black triangle gonna be going to be closed?

Having the conversation with the patient and them understanding that there are compromises. If you don’t, and I’m not anti prepping, I have schellenberg, I understand prepping teeth, but it’s about certainly with elective treatment, keeping it as minimal as possible. And with black triangles, the reality is you may well be doing a slice prep.

[Jaz]
But what I like there is what I’m learning is ’cause black triangles, those cases I have done in the past, they have been, for example, with orthodontics doing IPR to bring the teeth closer together to reduce the black triangles. Or often with composite, so we can just be complete additive.

But I had this misconception that when you have black triangles, you need to give it a vertical path of insertion, which again, is so much more destructive. But you’ve clarified that actually we can and should be doing the same facial path of insertion, even with black triangles. 

[David]
And that’s the key, is the facial path of insertion. And the lab would like to be able to take the emergence from the palatal. Okay. But again, think three dimensionally is that that may will still be possible with a facial path of insertion. But then we have the issue, we’re gonna have longer contact points. You need the skill ceramics to be able to build in the line angles so that they’re not looking like they’re long teeth.

[Jaz]
If anyone’s thinking if they’re younger than thinking of doing their first few veneer cases, please don’t do a black triangle case. And don’t do a, like a class three incisal edge relationship case with tricky cases. Do a nice easy case erosive wear and additive as much as possible. What other guidelines for your first few cases, what kind of characteristics are we looking for? 

[David]
I think again, it’s yes, simpler cases. Try not, maybe not a 10 unit case, a four unit case, absolutely. But also having a good relationship with your lab tech. And they will guide you as well.

[Jaz]
Totally. There’s so much we can learn, and especially the people who be making these veneers and you get all the glory, but they’re the ones who are doing the hard work behind the scenes, scanning versus impressing. So you’ve done, okay. Just one last thing on the Gurel technique is, have you found that when you are prepping through the mockup, as per the Gurel technique, that the actual mockup starts to flake away, break away.

Is there any way that you can keep the mockup there for as long as enough that you’ve got your perfect depth grooves without it sort of breaking away and visually obstructing the field? 

[David]
Very good question. Again, you touched on with the visual try. I find that the lock on works, I mean, when it comes to temporaries, I’ll spot etch them. Talk about that. But I don’t find you need to, and I suppose the answer to your question is let your luxatemp set fully. And once it’s rigid, it’s not gonna come off. 

[Jaz]
It is fairly well locked in. 

[David]
It will lock in. 

[Jaz]
It’ll shrink onto it. 

[David]
It shrinks onto it, it shrink fit and you can spot etch it, but I don’t find you need to. And the other thing to remember is that when you’re doing a Gurel technique, the luxatemp only stays on for your incisal edge reduction and your cervical grooves. I’ll then take a pencil and we’ve all seen the videos of- 

[Jaz]
Cervical grooves, just- 

[David]
Oh, not cervical. Your facial. 

[Jaz]
The mid facial grooves. Yeah, because you know what, I love that what you’re saying, and this is different to what I’ve seen before in other courses, is that they do say, okay, do the cervical, but I like your idea of not doing a depth groove cervical and kind of free handing that and to make your something for the lab to see, to give them just some guidance of where to finish. Right? 

[David]
Absolutely. And the reality is you can then get everything joined up when you are doing your preparation. But to help you with that, the bisacryl just stays on for your two facial depth cuts, which you pencil mark and then it comes off. Then you are left with either pencil marks or no pencil marks, and all you’re doing is joining up the dots.

And when it comes to the cervical, you just have a, by the time you’ve joined or you are microchamfer with the three planes of the reduction, you will find you have enough cervical reduction. That you don’t have to do the depth cuts. 

[Jaz]
Absolutely. Brilliant. In terms of at this stage, are you scanning? Are you impressing? What’s your preference? 

[David]
Well, you touched on this a couple of episodes ago, so I’ll agree with you that, scanners are great, but if you can’t see it, it’s not gonna record it. And when you’re looking at these micro chamfer, I think PVS impression that flows gives you a lot of detail.

Now, don’t get me wrong, that’s what works in my hands. I’ve got colleagues who do fabulous work digitally, and of course it’s all possible. But I do verti preps a lot. I have done retraction cord many times. I don’t use, I haven’t used retraction cord in however many years. I use a lot of retraction paste.

And since we’re on it, a top tip there is to tap it in with a pledget that you’ve wet and dampened and then squeezed dry. You could tap the retraction pace in. And I find that that gives enough retraction in that. But then the PVS impression flows a lot more. And if you’ve got a, maybe a prime scan, it’s gonna record it probably better than a different scanner that we can mention lots, we won’t go there. But it’s harder to record with a scanner than it is with an Impression. Yes. So- 

[Jaz]
Totally. I think if you’re want that highest quality detail, although scanners are brilliant and I think they’re getting there. But in terms of the crisp and the whole avoidance of doubt of that, the impression material has flowed in all the nooks and crannies, where the limitation is the light when you’re scanning.

[David]
But lots of colleagues managed to do that. But I haven’t seen their preparation. I know that for me, putting on a very micro chamfer, as you said, change of direction, that is harder to pick up with a camera than it is with an impression material that flows in. So generally I impress, but I respect people that do it with a scanner. And it again, like everything is what works in your hands, but you need to go in with your eyes open and understand the differences. 

[Jaz] I’m now gonna, in the interest of time, I mean, I could talk to you about days and I know you teach courses on this stuff and this is something that you can talk about for days and I’m just here just picking up these little pearls and gems, so thanks so much.

I’m really enjoying this so far, but I just wanna make sure we cover these little bits, contact lens veneers, the whole term. We see it in social media and stuff, but how do you feel about the term of contact lens thin? 

[David]
I think that’s for the marketeers, ’cause it’s the marketing term. Any veneer should be as thin as possible, therefore a contact lens. And so people, I mean, originally. When we have feldspathic, you might say, oh, we’ll just use completely clear feldspathic portion in there. And that’s where that it sucks in the color from the underlying tooth. Some people are using feldspathic and they have for many years, and it’s a great material.

But any, the near gonna, generally, unless it’s a high opacity, is gonna pick up color as long as it’s thin. So a contact lens is that you want to have the color from the underlying tooth. Other than that, it’s ultra thin veneers. Well, that’s another most- 

[Jaz]
You said, it’s not 0.5 millimeters generally, but in the cervical, how thin does it get?

[David]
0.3, I think 0.3. And then ultra thin veneers. Well, any veneer should be as ultra thin as you can make it. And I mean, we are additive again, for different reasons. Sometimes people want to give some more volume and rather- 

[Jaz]
So let’s say a class two div, two retrocline upper incisors. And then you have, you actually want to bring it out into the smile and you hardly doing any prep at that stage. Therefore, by the nature of it, you are gonna be thicker. 

[David]
You would, but then again, I’ve realized over 35 years that actually class two, div two is an issue because they’re gonna wear down their lower teeth and you put veneers on there, that’s probably not gonna help that situation. I’d say realign first. However, patients may not choose to, as long as they’re aware of the downsides, but it’s more that they have small diminutive teeth. And you’re right, a class two, you can bring it forward. But I’d be more concerned about the div two than adding to the facial because they’re effectively a restricted envelope of function. And over 50 years of 60 years of functioning, they’re gonna have worn lower teeth. 

[Jaz]
Spot on. And I know we could talk about vertical dimension, all those things ’cause that really preserves or makes your lower veneer prep so much, you mentioned that about making ’em so much more conservative as well. But in just time-wise, I’m gonna ask you what’s David’s favorite time-tested veneer, cement, resin cement that you’re using? What’s your favorite? 

[David]
Again, it sounds like I’m acting for a company. I’m not, but there’s a company that I particularly like. It’s all about the feel of the material you like. And there’s probably three market leaders we use in the UK, Variolink, Vitique, and Nexus. I think Variolink, they’re all great companies. Kerr, Ivoclar, DMG. Variolink for me is a little bit sticky, so it’s a much harder cleanup. But the way it’s formulated deliberately to be like that, that when you place a veneer, it doesn’t bounce back. The flip side is that it’s a very heavy cleanup. 

Nexus is probably in the middle for me. Vitique is light and fluffy, so it’s a much easier cleanup, but you have to make sure it’s fully seated against the tooth whilst you’re curing it because it will come back, it won’t stay in its position. So it’s a trade off if you want a sticky material to clean up or you want a lighter fluffier.

And just one other thing you said there that I think something to touch on is we’ve said we can be additive facially on uppers. We must have forget what about lower veneers now, lower veneers is historically problematical, certainly for a class one patient, but there is, and I wouldn’t advocate it as being entry level, but if you open vertical, it’s amazing what you could achieve. Because you can then have all the space you like. 

[Jaz]
You get your overjet and you get your lengthening. 

[David]
And patients that say, well, they’re open my teeth. And they don’t like showing their occlusal surface of their old teeth magically you get space. 

[Jaz]
Occlusal veneers. I’m actually gonna get a Pascal Magne on the show soon to talk about occlusal veneers. So I’m excited to delve deeper into that which is great. But I just wanna go back to the cements because I love the fact that you talked about it, not mentioning megapascals. ‘Cause actually they’re all really good. ‘Cause our substrate is enamel, right?

We’re using properties of protocols and it really, it does come down to handling and how you like it. So I really like how you did that rubber dam or no dam. What kind of cementation system do you like? 

[David]
Gingival health is essential, and I have done it both ways. But if you have someone that has good gingival health, you could rapid cement all 10 at a time. And the reason that can be a lot easier is if you think of you’re tiling a wall. If you put one tile out. All of your tiles are out. And so when you do 10 at a time, it’s not because it’s quicker, it’s because actually they tend to locate each other. And I’ve done it always, but you can’t do that unless someone has excellent gingival health.

So yes, you can individual butterfly each tooth and and do that. But the reality is the more minimal the preparation, the harder it is to cement one at a time. And so you’re not gonna have that location you would get from example, from a reverse three quarter crown. So as long as you have excellent gingival health.

And that goes back to making sure that things are healthy first. I will make sure that they can clean the gingival embrasures. I will encourage ’em to do that. And I have a couple of prepless cases that I show and it fit, it looks like they have back triangles. Well, they can’t talk ’cause I haven’t prepped the teeth.

That’s because they’ve been using TePes in their temporaries and TePes or interproximal cleaning. We shouldn’t go onto brands, but interproximal cleaning is essential. But I tend not to ask patients to approximately clean upper three to three normally, but with their temporaries absolutely. So with good gingival health, rapid mentation with the whole arch together is my preferred.

[Jaz]
I loved your tile analogy there. ‘Cause I think, I’m just guessing when you speak to dentists and they tell you about their veneer experience, they tell you about that. When I got to put my last veneer on, it just wasn’t fitting and everything. ‘Cause it is a common thing that we speak about with dentists and I think you just absolutely nailed it with that analogy. 

So thank you for that. David, honestly, I can speak to you for days. It is almost 11:00 PM now. You’ve got a full case through tomorrow. You are such a man of wisdom and experience and such good work. Tell us where can we learn more from you? Do you have any education that you put out there? I know you are involved with the BACD as well. Tell us about you and the organizations that you represent. 

[David]
So, BACD, absolutely always a great place to learn myself. I have my own site. I do teach with another Protruserati, Kushal at Ace. And that, I believe I did ask him because I do run this course as a day course, which isn’t a veneer course.

It’s a minimal intervention, but it is at least hands-on with the whole techniques we’ve been talking about. And that is ace-courses.co.uk. And we are just launching another colleague of mine, Elaine, we have a new website that’s launching, which is ppcontinuum.com, which is where we’re going to be putting a lot of our educational.

[Jaz]
Is that protrusive podcast continuum.com? 

[David]
So that will be coming shortly, but that is gonna be the web address where we’ll have a lot of basically online education that people can resource. So it’s both online and then hands on as well. 

[Jaz]
Lovely. I mean, like I said, I’ve been to your talks. I’ve seen you talk, I’ve seen you work on your patients. I’ve seen work being done on you as a patient, so I’ve seen every facet of it. So guys, please do to check out these, I’ll put these links in the show notes. And of course, ACE and, Kushal have all my love. I’ve done lots of Ace courses over the years, so I’m a big, advocate of those as well. I’ll put the links in the show notes.

But David, thank you so much for guiding us through answering our little questions. And I really appreciate, every time I see you at the BACD, you are just so kind and lovely and encouraging over the years. It’s been like six years of doing it. And every time I’ve seen you, just from the beginning, from year two, you were like, Jaz, keep going, keep going. And so I want to thank you from my heart for your encouragement. It means a lot. 

[David]
And Jaz, I’d just like to say, first of all, thank you for having me on. It’s been a privilege and it’s a great thing you’re doing. It’s a great community and well done. 

[Jaz]
Thank you so much. It means a lot coming from you. Honestly. It means a lot coming from you. Thanks for your time. And, we are gonna both need some sleep. 

Well, there we have it guys, thank you so much for listening all the way to the end. It’s always a pleasure to host lovely people like David, who is a Protruserati. Honestly, it just makes me so happy having members of the community that I get to interview them and learn from them.

Like, I always thought black triangles, you have to go vertical path of insertion. But he corrected me. You can go facially. And of course, as I say, these guests that come on, I want you to support them if you resonate with any guest. Go on one of their courses, learn from them. You’ll never, ever, ever regret investing in yourself unless you invest in yourself, and then you don’t get to actually apply that technique.

So if you don’t have many veneer patients, maybe do a technique whereby you start identifying suitable patients and then telling them, look, I’ll be soon going on a veneer course. Would you like to be one of my first patients? I know for some of you that may sound crazy, but why would you want to ever lie to a patient that I’ve never done a veneers before?

And yeah, I’m used to doing it all the time. Like you’d never want to be in that scenario. In my experience, whenever I’ve done techniques for the first few times, I’ve been really honest to my patients, and you’d be amazed how well this works. Patients are so trusting and when you tell them that, okay, I’m literally just going and I’m learning from this awesome dentist, and while it’s fresh, I’m gonna come and I’m gonna help you with your smile.

And so I’d like for you to be one of my first patients, just give you some ideas, guys, in terms of how to actually start implementing and applying all the knowledge from the courses you gain. Of course, mentorship is so, so key. So now by the time this episode comes up, we’ve launched intaglio mentoring.

So the website is intagl.io. It’s intaglio, right? And so this is the online mentorship platform that we have created. So let’s say you have a veneer case coming up, or you’ve got loads of smile photos and you’re just not sure how to treat this case, like should you do veneers? Should you do ortho first?

Should anyone, these are be crowns. How long should you make the teeth? Do you need to open the vertical dimension? All these questions that you may have, you can now go on intaglio. There’s so many great mentors on there already, and we’re just in the beta phase, right? You can identify them, you can see when they’re available, and you can book them for like an hour, two hours, wherever you want on Zoom.

Show them your cases and let some people who are experienced guide you. What I’ve found from being on both sides of the equation, being a mentor and also being mentee, even last year I was paying a handsome sum of money to be mentored for some complex cases. It is a phenomenal return on investment and it just really is like a rocket for your career.

So do check out Intaglio if you are interested, if you need a mentor, or if you are in a mentor and you want some mentees, we want you come and make your profile on Intaglio. We’ll look after you. Thanks again, guys. Don’t forget to answer the quiz for CPD or CE credits. We are a PACE approved provider and I’ll catch you same time, same place next week.

Bye for now.