How to Shade Match the Single Central Incisor – PDP165

Jaz’s Introduction:
So we rely a lot on our lab, but the communication to actually get that color, that shade perfect, can be really challenging.

Now, as you guys know, I do a lot of resin bonded bridges. And so I do face this challenge a fair bit, trying to match a pontic of a lateral incisor, for example, or a lower central incisor to the adjacent teeth can be really tricky. So I’ve been stung a few times whereby technically my bridge has been awesome, but the shade has let us down.

So this is a real art. This is a real tricky thing. But today we’ve got Dr. Imi Nasser, who’s going to share his entire protocol with us. Imi’s one of these annoying dentists on Instagram, right? He is just brilliant. at everything. Like you see him post a class 2 restoration that’s just absolutely flawless, and then all of a sudden he’s doing all the soft tissue grassing, temporization, and a beautiful single central incisor that matches flawlessly to all the other teeth.

And you think, how does he do it? And he does it consistently, time after time after time. I’ve seen him post central incisors, lateral incisors that are just shade and characterization perfect. So I asked him to come on the podcast to spill all the beans. How can we take the stress out of shade matching and how can we make sure we nail it every time?

Because the crazy thing in here from today’s episode is that actually, Imi doesn’t bring his patients back for like a try in and a retry and then send the patient to the lab to get a custom shade. He doesn’t do any of that, right? It is just amazing. His level of communication is fantastic and that’s how he gets great results and we’re going to share that all with you today. So don’t go anywhere, Protruserati.

Hello, Protruserati, I’m Jaz Galati, and welcome back to the Protrusive Dental Podcast. I’ve been a bit sick for a few weeks, so I haven’t been in front of the camera. Finally almost got my voice back fully. I think it’s some nasty bug that’s been going around, and it doesn’t help that I’m not sleeping much because I’ve got a six-month-old baby, like my son, Sihaan.

Great kid, bad sleeper. So it has been a challenge and a shock to the old immune system, but I’m finally getting back to my best. Sorry that I had to cancel a monthly grind coaching course. So every month of my split course, we do like a coaching call. We see how everyone’s doing and wanting the help and support with their cases.

So I had to cancel on that and I had to recently cancel my Verti Prep for Plonkers webinar, which is now been moved to next week. So keep your eye out in your emails for that. So I’m sorry for the first time I had to reschedule these but thank you so much for all of you being so understanding actually through this, I’ve done the trickiest thing I’ve ever had to do in my career.

I had to give a five hour keynote presentation to a group in Devon, the Devon Independent Practitioners Group. Great bunch of dentists, right? Really nice and caring. And it was great to be in Devon to teach, but this was while I was still sick. So every now and then I was blowing my nose, I was sneezing, coughing, and it was a professional challenge to deliver a lecture.

The title was Bruxism for the Restorative Dentist from Splints to Smile Design. And it really challenged me to try and make it as engaging as I usually try and make my lectures and pack full information, pack full of gems. So it was a real challenge to deliver that while I was still sick.

I just didn’t want to cancel on this lovely group of dentists. And please say it went well. And I just want to say a big shout out to Devon IPG for looking after me, especially Natalie Miller, Dr. Natalie Miller. She brought the best Home brewed, ginger, honey, lemon tea. It was just amazing. It was exactly the remedy I needed. So, Natalie, that was so caring of you. Thank you so much.

Protrusive Dental Pearl:
Every PDP episode, I give you a Protrusive Dental Pearl. Now, this one’s very relevant to what we’ll be talking about. So, Imi and I will talk about how to take really great photos so your lab technician has the best chance to match the ceramic work to the adjacent natural teeth.

And so, part of the protocol is to take cross polarized photos. I’ve talked about this before. It might even have been a pearl before, but let’s talk about it again. When you take a photo with a ring flash or even a twin flash, the issue we get is that the actual flash itself is reflected off the teeth and then the camera picks up these, this like specular flash as we call it, and these intense spots of flash on the teeth.

The problem with the flash is that it hides some of the details of the tooth. You kind of almost want to have a minimal impact of the flash. You kind of want to see through the tooth. To see the full anatomy. This is why in the market exists something called a cross polarizing filter. You can get one for the ring flash, like I do.

You can also get one for a twin flash. And the way it works is that it removes the specular flash. So the image that you get gives your technician so much information about the characterizations and the shade without that horrible flash disrupting your photo. I think if you really want to elevate your shade taking game, and also if you do a lot of icon resin infiltration and treatment of white spots, this is a really great thing to have actually.

You get to see kind of like the depth of the white spot and it makes for great before and afters to actually see the detail through the teeth. It can be a little bit pricey when you get the sort of the top branded ones, but we made a video not too long ago about how you can make your own DIY cross polarizing filter.

Now, if you’re anything like me and you’re far too busy for that, a shout out to Darren Tsang Dr. Darren Tsang by the way, who did that episode. So we’ll put that in the show notes if you want to have a go at making your own one. But there’s also someone called Daz. Daz is on our Facebook group, Protrusive Dental Community, and he makes you your own customize, personalize one with magnets that you can fit on your camera.

So now you’ve got no excuse not to get one. If you go on the Protrusive Dental Community Facebook group and reach out to Daz, Daz will sort you out. I have no financial interest in this. I just think he’s great that he’s helping Protruserati out to get the benefits of a cross polarizing filter for a fraction of the price. So thank you Daz for being a great member of the community.

Now before we join Dr Imi Nasser in this inspiring episode, I just want to say is I did use this word inspiring in the main episode as well because I really felt inspired to do better. I really felt inspired to actually nail the shade matching and get rid of these limiting beliefs that I had that the patient had to go to the lab to get the best result.

The patient had to get multiple try ins to get the best result. So still we want to undersell and over deliver, but Imi will go a long way in teaching us how to get more predictability because that’s ultimately what we want. Now, before we join that main episode. Final, final update, which is, those of you who’ve seen my Instagram and my upload to YouTube as well, I’m helping this little girl called Nafisa.

We need to help Nafisa who suffers from something called SMA type one, and it’s basically muscular atrophy and she struggles to breathe and swallow. And it’s really urge you to go on my Instagram and watch the video or on YouTube, which I’ll upload it to, but we’re raising money. We need to get 1. 8 million before she turns two to get this genetic therapy that could be life saving.

Right. So why am I talking about this? Because actually she’s the daughter of one of you. One of you reached out to me. Her name is Sakina. She’s a dentist in Tanzania and she reached out to me asking for help and I just felt compelled to do something. I want the legacy of this podcast is that we helped Nafisa, which is Sakina’s daughter, to raise enough funds to get the genetic therapy she so badly needs.

I just want to say thank you so much to all the Protruserati who’ve donated already, or even if you just shared my Instagram post. That really meant a lot. Thank you so much. And so now we’re up to about 650, 000 raised already, right, for this cause. But we still need to keep going. So I will keep updating you episode to episode how we’re doing to help Nafisa. I’ll put the GoFundMe link in the show notes and I’ll remind you again the outro. But let’s join Dr. Imi Nasser on how to match the single central incisor.

Main Episode:
Dr. Imi Nasser, we finally meet. You are a Protruserati that I’ve been in touch with on Instagram. And I’m in just awe of your work. You are just brilliant. Before we hit the record button, I was just saying all these wonderful things about my experience with you so far. Welcome to the Protrusive Dental Podcast. How are you?

[Imi]
Yeah, very good, Jaz. I mean, I can’t believe that I’m actually finally on the podcast that I listen to the most. So, thank you for having me. I’ve heard so many great people that have sort of been questioned by you, but I think on those drives that those long drives up the M5 that I used to do, it’s just, whether it’s your voice, whether it’s your enthusiasm, the whole lot of it, I mean your energy for education is just so infectious. So, to actually share an hour together to chat about something I love is just a privilege.

[Jaz]
Well, I just want to say if anyone who hasn’t seen Imi’s work, we’ll put a link in the show notes. You really are, it’ll be a sin to call you a jack of all trades because it would imply that you’re a master of none.

You’re like a master of all trades. It’s just beautiful to see the work that you do. And I’m so glad that we can pick your brain today on such a tough topic, right? Matching, it’s known to be the most difficult thing in dentistry, matching the single incisor, shade matching. That’s the main focus of today.

And I always think like when it comes to implants, especially like already, one of the reasons that you may be doing an implant for someone in the anterior maxilla is it’s trauma. So already you’re having a lack of bone or whatever you have to do grafting, ridge preservation, all these kinds of things they have to do.

And on top of that. Then the final thing to worry about at the end is actually again, the most difficult thing once again, which is shade matching. And you do it so consistently, so beautifully. And you told me again in the earlier, before we hit the record button today, that you fit a single veneer as well.

So I am so excited to learn myself in terms of how we can make it more predictable for ourselves. But before we delve deeper into that, Imi, just tell us a little bit about you and your journey. How did it get to where you are? How did you fall into the lovely variety of the day you have, which is a bit more of a bias towards surgery and implants.

[Imi]
Yeah, I think, when I compare the two, of course, Jaz, you just touched upon it there. I think, shade matching for implants is very different to shade matching for natural teeth. Because, of course, there’s core structures that you’ve got to be sort of aware of. But, for me, my love of these areas of dentistry has probably come from my SHO days.

So, I qualified 17 years ago from Bristol and there was a life before that, born and bred in London, but eventually found myself in Bristol as an 18 year old. And then once I qualified, I did Max Fax for a year. And that was down in Bath, and then I did restorative dentistry for a year at Bristol.

And actually, that perfectly sums up my journey, where, I have my love of surgery, but then I kind of feel that I want to do the final piece of the jigsaw. I want to give the patient the tooth at the end of it. So, if I look at one of my usual days, it will be a morning of normal surgery.

Whether that be bone grafting, whether it’s implant placements, whether it’s sinus lifting, usually a bit of soft tissue grafting. Pink aesthetics is so important when we’re talking about ceramics or what have you, there’s so much involved. And then my afternoon will be full of a composite filling, and then maybe a fit of a restoration.

The only thing that I don’t deal with is orthodontics. So, we have four orthodontists in our practice, so, I leave that to them. But the rest, I love to do. And actually, there’s nothing more pleasing than when you give that patient that final fit. And actually you’ve exceeded their expectations.

And I know normally, people are trying to not raise their patient’s expectations because they worry that they can’t deliver, but actually, at the forefront of my treatment protocol, I tell the patient that I will be able to give them what they want. And it doesn’t matter how long it takes me to get there, we will get there.

[Jaz]
Well, one things I’ll be probing you on is exactly how long it does take because in my experience of speaking to some great clinicians, they said, oh yeah, we had to try this in four times to get it right. And part of the discussion I wanna have with you is, okay, are you a one hit wonder? Are you really this elusive unicorn? Or is there something behind the scenes about sometimes it has to go back to lab and whatnot. So the whole struggle of it, I’d love to learn.

[Imi]
Yeah, so I mean, if I could tell you the honest truth, Jaz, I cannot remember the last time I had to send a restoration back to be adjusted or to be changed at all. So, my fit appointment is always labeled as a trying appointment. And I tell the patient that we will try and if I’m happy, I will restore it. If I’m not happy, it will go back for tweaks. I’m very lucky that I work with great laboratories. But actually, I think the key I feel that I could get that with a few laboratories because it’s all communication.

So I pretty much give them every detail you can possibly think of. And then there is no excuse, especially when it comes to single central incisors. And we will talk about a couple of tricks that I use that I feel that, really, a hundred percent of the time you can hit it.

[Jaz]
That is absolutely amazing. I’m even more excited now for the rest of this podcast. And for those who are watching on YouTube, you saw my jaw drop when he actually, I was actually begging, expecting to say, well, actually, yeah, 2. 5 is about the average time you’re going to send it back. It’s amazing that you’ve just got this system nailed.

I’m so, so excited to get to the meat and potatoes of this. Right. So that is so exciting. That’s so cool. Firstly, for those mere mortals, why is this a challenge, right? Just go back to basics for the younger dentists. Why is it that we perceive matching, shade matching the single incisor, which is the main topic, right?

Let’s go for the, the kill. Let’s go for the main tricky one. Why can this be such a tricky thing? And then, you touched on it, upon it already. Is it harder? When you’re trying to do maybe a veneer, on a natural tooth to an adjacent tooth or an implant to adjacent tooth, I want you to come onto that in terms of what is actually more difficult when it comes to shade matching, but why is it generally such a tricky thing to do?

[Imi]
Okay, so, I think let’s first start with, for those, let’s think about those that aren’t doing implant dentistry and we’re just talking about a single tooth. And I think really it goes back to people’s understanding of materials and material science and all that stuff we were taught at dental school that we thought that was irrelevant.

But actually, we have to think about the tooth structure and actually what we’re trying to achieve. So sometimes we may be asking too much of our technicians. We’re not giving them enough space. But yet we’re trying to ask them to mask a discoloured core underneath. And there’s a limit to what they can do.

So say for example we’re talking about lithium disilicate. And we have an ND, if we’re using our stump shade guide and we’ve got an ND4 discoloration underneath there. Well, I know some people might just write on a lab prescription, I want, can you make me an Emax veneer? So, at this stage, is that enough, I want an Emax veneer in A3.

Standard, standard prescription. Now, how I would break that down is actually, we know that Emax is the trade name. We know in this instance that the clinician wants lithium disilicate. But actually we need to think of the translucency of that material. Okay, so at the very basic, before we’re even thinking about the shade of that veneer, or that lithium disilicate, we need to think, do we want a high translucency?

Do we want medium translucency? Or do we want low translucency? Okay, so if we’ve got a darker core underneath there, of course we need an LT. Low translucency Emacs veneer. And, of course, we still need to hear-

[Jaz]
What about M. O.? There’s also M. O. and H. O. as well, right? Do you ever use those? Which, by the way, for the younger dentists, medium opacity, high opacity, and also, I do want you to cover, because you touched on it, is what does stump shade mean? For maybe many, many years ago, I wouldn’t have known what that meant. What is a stump shade?

[Imi]
Yeah, so, I think when we do our shade taking, say, for example, we will go through this in detail, hopefully, Jaz, but usually as soon as the patient comes into the room, I will do my full workflow, step by step, of my shade protocol.

The only thing that I won’t do at that stage is, of course, the stump shade. And the stump shade is only produced once you’ve done your preparation of the tooth. Essentially, I use a shade guide from Ivoclar. Which has the natural dye colour sequence, and from ND1 to ND8, you get a range of discolouration.

And essentially all I will do is I’ll put that stump shade next to the tooth, and we will reference that with a photograph. Being very mindful that that stump shade is actually in the right plane as the tooth, the light’s reflecting on it properly, it’s not behind the tooth, it’s not in front of the tooth, it’s exactly edge to edge.

Otherwise, it’s of no use to your technician. I’ll choose, I’ll find out what my exact stump shade is, and then I’ll choose a shade which is one lighter and one darker, and at least we’ve got a clear reference. So I would usually take about three pictures of that. The other thing that I think is really important when you’re taking those pictures, I’m covering a few different areas, is that I think it’s really important to use a twin flash.

I think on any of these single central cases, if you use a ring flash, you’re always going to get a reflection of the flash in the tooth, and you’re going to hide a lot of the details there. So, anybody that’s looking to do these type of cases, worthwhile investing in sort of a twin flash setup. So you’re lightening it from the angle, and that you can see actually the line angles on the tooth.

[Jaz]
Wonderful. And then back to that point about you mentioned some ingots and you mentioned LT, low translucency, which I would agree to try and hide a darker tooth, but you’re not venturing, you said you’re not using the more opaque lithium desilicates, the ingots?

[Imi]
Yeah, so I find, I mean, and to be perfectly honest, I would say that single veneers or veneer work is a low amount of my workflow, so I think if you were speaking to someone that was doing veneers all day, every day, then they probably would use some of those ingots more often.

Majority of my cases, veneers are few and far between from me. Usually, most of my stuff might be replacing older PFMs, and in those instances, I would always use, sort of, zirconia. And layered zirconia buccally, because of course, with masking cores, zirconia is very opaque, and it works beautifully for that.

For me now, zirconia has taken over the majority of my workflow for a couple of reasons. Number one, posteriorly, I think monolithic zirconia, now with external staining, is just utterly stunning. And we don’t get any of the chipping, we don’t get any of the breaking, and with the right laboratories, it’s beautiful.

I mean, anteriorly, with buccal layering, with ceramic on zirconia substructure, you’re really producing a strong restoration with optimal aesthetics. And when we’re talking about implants, then zirconia gives us lots of advantages, obviously, subgingivally. But I think, for me, the majority of my anterior single unit crowns, I would be looking to use that.

To me, matching a single unit implant, or a natural tooth, I think really shade, before we come to shade, I think shape is everything. So, if you’ve got the primary form right, if you’ve got the secondary and the tertiary anatomy right, even if your shade is slightly off, I think it still looks beautiful.

So I think that my primary focus is on shape. And one of the tricks that I do with that, I’m sort of moving all over the place, one of the tricks I do with that, Jaz, is I actually, one of my final pictures, with the missing tooth, I will put it into Keynote, and I will actually flip the image, cut it out, and superimpose the other central incisor into place.

So, I send that to the technician with my false prescription so they know exactly the shape that we need. And actually, what that really helps me identify is if there’s any risk of a black triangle somewhere. So at that stage, I can communicate it with the patient that, hang on a second. In the midline here, we’re going to have a black triangle if I mimic the shape.

If we change the shape slightly, we can get rid of that black triangle, but it’s not going to look as asymmetrical. What would you like me to do? And I love playing around with it on Keynote, and actually showing them me playing around with it, and then we agree on that before I send it off.

[Jaz]
So what I love about that is the whole co diagnosis component. The patient’s there with you. They get to see it and they will get to make more informed decisions. It’s not you trying to upsell additional restoration. It’s actually you discussing a potential pitfall of going back the way and then they get to see that, which I love. And also you touched on something which the composite gurus all say, right? Shape with a P is more important than shade with a D. So totally, totally concurred.

[Imi]
Absolutely. And when it comes to implant, of course, the challenges are that number one. The pink aesthetics has to be right, so the gingival zenith has to be correct. Number two, of course the ceramic, the white aesthetics, has to be right.

There has to be a harmony between the two. And of course, as you know with composite work, the black aesthetics, so the abrasions, the mesial notches, the distal edges, all of that has to be in harmony. And if that is, then actually shade matching an implant, I feel, because you’ve got no underlying core, is so much easier. It’s so much easier if you follow the protocol that hopefully I’m going to talk you guys through.

[Jaz]
Well, let’s address it now. So, we know it’s a challenging thing. It’s the most hated thing in dentistry. We always worry about how many retakes it’s going to take in fact, it’s a patient about this kind of work, I say, okay, we can try it, but it’s never going to be perfect.

It’s always going to look a little bit different because that’s how they are. There’s no technician that will match it perfectly. And to get it to the right level. We’re going to have to go to lab a few times and give them the whole workup and the preamble, right? Which we do as part of our consent process in the future.

I just say, listen, go see this guy in Cheltenham called Imi. Just he’ll sort you out. Basically, I might change my tune now. But we’d love to learn from you, my friend. What is your protocol?

[Imi]
Yeah, okay. So, I think the first one is, as soon as the patient comes in the room before local, I will sit the patient up and we will do the shade assessment.

Now, the most important thing for me is that, number one, at that stage, your eyes are fresh. There is no fatigue. The second thing is that I try, I have the patient sat upright so they’re at eye level so I can see it all properly. Of course you want things like natural daylight as much as possible because that, all those other things around it can influence our perception of shade.

Patients with red lipstick, that potentially could cause an issue with your perception. So the first thing that I’ll do is I’ll just use my Vita Classical shade. And Shade Guide, and I will just try and work out what the value of the tooth is, so those of you that don’t know, the value is essentially the brightness of the tooth.

Okay, and the Vita Shade Guide, mine is always set up, not from A1 to D4, it is always set up in order of value. So those of you that don’t have it set up like that, do get it organized in that fashion. So, usually, you can identify the value of the tooth fairly quickly, and I think at the very least, we should be able to see a different value from the cervical aspect, the body aspect, and the incisal aspect.

So no tooth would be one single block colour, there must be at least three shades within it. And that’s kind of a bit of a start point, for me, if, say, for example, Vita Classical gives me a pretty good match, I start to feel uncomfortable, because I think, Jesus, this is too easy, we need to make it a little bit more intricate than that, so then I go to actually, I usually use the 3D Master Shade Guide, and as we know with a 3D Master Shade Guide, there is a lot more shade tabs involved.

And actually what it’s looking at is the value, it’s looking at the chroma, and it’s looking at the hue of the tooth. So we spoke about the value, that is the brightness. The chroma is actually looking at the intensity or the saturation of the hue. And the hue is really looking at whether the tooth is quite red or is it quite yellow.

So, first of all, when you’re looking at that, you’re only looking down with the Vita 3D Guide. You’re looking at numbers 1, 2, 3, 4,5, and you’re just trying to find where your tooth is landing. Then, of course, you’re looking at the chroma, and you can nail that down. And then finally, there’s the Q setting, which will be whether you use the L tab, the M tab, or the R tab.

And actually, usually, if a patient is around, most people will be around 2M1, 3M1 if they’ve got the average shade. The beauty of that shade guide is that anything sort of obscure between the Beta Classical, you can always pick it up within that. Now, the next shade guide that I go to, which I’ve found has been my game changer, has actually been the Vivodent PE shade guide.

And, I don’t know if you’ve used that one. But, what I find with it is that it’s got a very natural characterization, especially for incisal edges. So all of my sort of incisal thirds of the tooth will all be referenced by that shade guide. And it’s very, very different to the VitaPan 3D or the Vita Classical. So, I would strongly suggest that-

[Jaz]
So essentially when you’re giving a prescription, I’m sure you get this anyway, when you’re giving a prescription, you’re mixing and matching the shade guides, right? So, you’re giving a VivoDent for the incisal third, you’re giving a Vita Master for the middle, is that right?

[Imi]
Yeah, so they’ll either be, exactly, there’ll be a VivoDent P for the incisal third, there will be a mixture of VitaPan 3D. And Vita Classical for the cervical third and the middle third.

[Jaz]
Got it.

[Imi]
And I think what’s really important when you’re actually doing it is that obviously not to dry the teeth too much because you will desiccate them and you will increase the value.

But also don’t look at it too long because if you look at it too long the fatigue will creep in. You almost need to make spot decisions and be very good at just picking that up. I think, at that stage, once I’m happy with it, I will then pick up my Smarlite handheld device. So, my the Smile Lite which is from Smile Line they make it in Switzerland, it’s essentially a handheld device with a little window, which will essentially cut out all the external whether it’s dark outside, whether there’s shadows.

It will basically give a standardized light of 5, 500 Kelvin. So natural light. And essentially I’ll look at all the tabs through that before I put the polarizing filter on it and double check it with that and the polarizing filter will obviously reduce the glare and you can internally see if it’s sort of matching up nicely.

[Jaz]
How does that compare to a cross polarized photo? I’m sure you’ve got this anyway, but like, can you take a photo of that? The smile line is just a light source, and then you’re taking a photo of that. How does it work actually transferring that to the lab?

[Imi]
Yeah. So thereafter when I take the photos, so then after I’ve done that and I’m happy that my choices are correct.

So really that handheld device is ensuring that my decisions under normal lighting are correct. Then I will start taking my photographs. So, essentially, I will do my first round of photographs with bare flash images, with no diffusion and no polarizing filters. Okay? And that will be with a twin flash to ensure that I’m not putting too much glare on the front teeth.

Once I’ve taken one picture with the bare flash, I will do my range of shade taps one by one next to the adjacent central incisor with the bare flash.

[Jaz]
Yeah, let’s talk about retraction as well, using normal retractors to retract the tissues out the way here.

[Imi]
Yeah, so I use black retractors, which will essentially be half retractors, so they will just sit up in the sulcus here. And not upper and lower, just in that anterior zone.

[Jaz]
Got it.

[Imi]
Yeah, so, my assistants will be standing behind, they will hold the retractors. I will hold the tab in one hand, because I find otherwise if you leave the assistant to do it, it might just come in front of the tooth, it might go behind the tooth.

So I’ll hold that, and then I’ll shoot with my other hand. So, with the bare flash, I will go through each shade tab and take a picture with it. I will then put some light diffusion onto my flashes. And I will take all the shade tabs with my diffuse images as well. And for those of you that don’t use diffusion on their flashes, essentially that just softens the image slightly.

But I see lots of pictures taken where people use very diffuse images, and that just kills all the detail. So it’s important that you’re using not too gross a diffusion, if you want to transfer the information to the laboratory. Once we’ve done that, I do my round of pictures with the polarizing filter on my flashes as well.

And then to finish off, I will take a lateral shot, which is the only way I find that I pick up the surface texture. And this is really important if we’re doing digital scanning, that at least you can give the tertiary anatomy to the technicians. Yeah, fine. So then the third part of the photo protocol is to take the pictures with your polarizing filter on your flashes.

So that you’re giving your lab polarized images, so that they can see the internal characteristics. And this is when the laboratory can see the crack lines, they can see the opacities, they can see the CEJ step, they can see the halo around the incisal edge. These polarized images is the only way that they can pick up that detail. And then the final-

[Jaz]
Which brand of polarizer are you using? Just while we’re on this, what brand are you using?

[Imi]
So I use polar eyes. So two words.

[Jaz]
I’ve seen that one. And then, obviously you can’t use your Smile Lite you can’t use that to take a polarized image. Right. You can’t use that as a polarizer, right?

[Imi]
Yeah. You are only using that for your own vision of what the site looks like under polarization. Essentially, you can’t take a picture through that. And then the final picture that I take is actually a lateral picture with the retraction in place.

And I find that, of course, if we’re using traditional impressions, you pick up all the surface detail. But nowadays, where we’re using so much digital, the only way to transfer that tertiary anatomy to the laboratory is to take that angled shot and you can see all that anatomy. And that will allow them to put those sort of, those striations into your ceramic work.

[Jaz]
Is this like a one to one, like the maximum zoomed in on a hundred millimeter lens, for example?

[Imi]
Not really, not necessarily. I mean, I will still have the nip in view. I will still have all the anterior teeth in view. It will usually be because I’m holding, usually holding the tab. It will be an auto focus. The ratio that I set it up into, it will change slightly, but my working distance, I work with a 60 millimeter working distance. So I use a 60 millimeter macro lens.

[Jaz]
And a pragmatic question is just switching from the bare flash to the diffuser. Are you just slick at putting the diffusers on, or have you got a setup which is bare flash and a setup next to it, which is the diffuser one?

[Imi]
Yeah, good question, Jaz. So I have two setup. So I have three cameras there. The problem is, is that I love my 90D. So what actually I end up doing is I end up taking the picture with the bare flash, and then I put the diffusers on that one. So I actually use one camera for all of the pictures.

So the seven, I have a 77D as well, which is a great camera, but the megapixels is so much better on the 90D that it doesn’t, I can’t cope with using the 77 for any of the pictures, basically.

[Jaz]
Well, I’m feeling really great because I’ve also got the 90D, so I’m feeling great. And that was just like a random decision making at the time.

So next time someone, I would say, people ask me at Jaz, what camera do you recommend? And I always say, look, speak to Minesh, speak to these guys. These guys know what they’re talking about. I use a 90D, but now I’m going to say, hey, I use the same one that Imi uses, go for a 90D. I’m going to say that with confidence now. A lot of people moving to mirrorless. Is that the way you think it’s heading?

[Imi]
I mean, that will be the next way it’s going. But the thing for me is that I think it’s really important that when you recommend stuff to people, it has to be affordable and you want as many people to use it as possible.

And the beauty of the 90D is that, it’s a cropped sensor camera, which means it’s so much more cost effective than one of the full frame cameras or the mirrorless ones, but the megapixels on it are insane. So actually, for me, I would rather have three or four cameras that are cropped sensors.

And still take beautiful, for me it’s about, really about flash positioning. If you can produce, if you can put your light in the right place, you will produce beautiful pictures. The body, fine, yes. And the lens, it does a certain amount of work. But if you’re good with lighting, you can produce beautiful stuff with anything.

So, I don’t think people necessarily need to spend two and a half, three thousand pounds on a camera body. When, say for example, the 90D, I think it cost me about six hundred and seventy nine pounds. Such a great investment for reflecting on your own work and all the rest of it. And of course, sharing and sharing with others.

[Jaz]
Well, let’s make it really tangible. We’re saying what you’re saying in the protocol. I love the way it’s going and it’s great to get that insight of the side photo and the three different lighting conditions essentially, one with a bare flash, one with the diffused, one with the cross polarizing filter.

A lot of people thinking like, whoa, so many photos, but you need to give this information to your lab. Just the only way I want to make it more tangible is let’s give this an example scenario. So all this time we’re talking about matching a crown. So we’ve got a, let’s say an upper right central incisor crown that we’re doing, and we need to match it to the natural upper left one.

So then we just keep that in mind as you’re going through a protocol because there’s so many, you probably tweak your protocols on the scenario, but if we can really go deep into one protocol, we can probably change it for the other protocols. And also ultimately, I think people should go and learn more from you anyway, to, to learn little nuances, but just, yeah, yeah, let’s go. What’s the next step thereafter?

[Imi]
Yeah. So at this stage, okay, so we then gone into. So that’s pre op. Okay. So at this stage, I’ve already identified all the details within the contralateral central incisor. Okay. Because of course, as the appointment goes, the tooth is going to, as we start doing treatment, we pull the lip back.

The tooth is going to change color significantly and all the opacities are going to change within the tooth. Then we will go ahead and do our prep appointment. And at this stage, we will then take, once the tooth has been prepped, and we’ve got sufficient clearance for our ceramic, et cetera, we will take our stump shade guide.

And that’s with the Ivoclar one that we mentioned, so the ND shade guide. We’ll obviously then do our provisional. And with the provisional, sometimes I will customize it as well. So, of course, we will use temp phase or pro temp, but often at this stage, sometimes people don’t give a lot of value to the provisional.

And actually, that’s when the patient starts seeing the value of what they’re paying for or what you’re trying to achieve. And that’s really part of, I’d almost say it’s part of my consent process. That I’ll maybe lengthen the tooth slightly, or I’ll play with the angles, I’ll sit them up, looking at them like, oh, do you like this?

And then I’ll picture it, send it to the lab, that, look, this is what it was like before. Yes, I took a pre op scan, but actually we’re changing it to this. This is how we’re going with it. So actually, we’re getting a lot of consent for the final shape of the tooth. But actually, really where the most of the, once I’ve got all of those images in the bank, the real flair then comes thereafter.

And really, that’s when I start playing with it on Keynote. Okay, so usually, with that central incisor, I will cut the contralateral central incisor, I will flip it over, and I will put it into place on Keynote. Then, I will export that into an image, and that’s when I’ll start doing my annotations. On just on Apple Photos, I will use the markup app, and I can start drawing on there exactly what I want the laboratory to replicate. Now, the first thing to say, I would mark on that.

[Jaz]
And so I don’t leave too much to the imagination, Imi. If anyone just goes to your Instagram, they can see examples of this, right? If you just go to Imi’s Instagram, he just has so many beautiful examples of this. So, for those who really want to home in on this, just check out Instagram. Can you just tell everyone your instagram profile so they can just check it out.

[Imi]
Yeah, so it’s Dr. Imi Nasser, and you’ll find some of these posts, I call it implant graffiti or dental graffiti. And essentially, that’s just me on my iPad. So, this image that I’ve taken of the patient, I will flip the central incisor, I will export it as a photo, and then on my iPad with a pen, I will be able to annotate it.

And essentially, what I do is, I’m very specific that when I send my work to the laboratory, I don’t write any instructions at all. And one of the reasons for that is that I want to make sure that they open that blueprint that I’ve created. And all of my information for the shade matching is on the blueprint. Okay, so they have to look for it.

[Jaz]
Genius.

[Imi]
You give them absolutely nothing, so they have to open it. Okay, on that one slide. On that one slide, it’s got the photo, it’s got the flipped image, and it’s got everything, okay? And I mean, so we start with the basics, okay? So then in every different area, I will label on there what shade we’re putting into it.

Then on the contralateral, the natural tooth. I will highlight anything that we need to mimic. So I will circle it with a bright color, and I will write white opacities to be copied. Internal crack line. So, if there is a crack line, I will look at it to the detailist. Is this internal, or is this in the surface?

If I think it’s in the surface, I will draw it onto the flipped image, and I will say use a sharp glass scribe to put this crack in onto the external surface. So, I will specify exactly where I want the halo. I will draw where the halo needs to go on it and actually it then, for those of people that post on Instagram, et cetera, these sort of photos become very reproducible.

There’s very nice content that people love to see and people learn from. So, there’s multipurpose uses of them by the end of it, you’ve got loads of annotations on there, you’ve got one picture, you’ve got one blueprint chopped up. And actually I find if you’ve given that laboratory that much information with polarized and diffuse images and a photo of the tertiary anatomy, then there is every chance that they’re going to produce for you.

But obviously you’ve got to do your part. You’ve got to give them enough thickness that off the right material. You’ve got to give them space. You’ve got to think of the emergence profile. There is lots of things to consider, but I think in harmony, if you communicate it. You will get back from your lab as much as you put into it. So if they see you’re putting that much effort into it, you can guarantee you will get the same back.

[Jaz]
In your journey of developing this technique and working with the technicians, did you have any hiccups at the beginning? Any tweaks that you made to the protocol? Because you found actually one thing had a big yield or change in result in terms of predictability. Any feedback that technicians gave you along the way to try and get it to be as predictable as possible?

[Imi]
I think, I mean, it’s funny that I’ve never really have had to have many conversations with my technicians at all. And I think that’s probably testimony to the protocol that everything is absolutely there. I think there was a time, maybe about five years ago, that I did a few cases using the elab digital shade protocol.

[Jaz]
I was going to ask you about that, yeah.

[Imi]
Yeah, so, I used elab and I’ve got the white balance card. And for those of you that don’t know that protocol, essentially you’re taking images with a reference card at a set F stop and lighting ratio with a polarizing filter. And essentially it helps the technician break down the multiple shades of the tooth. And I found with that, that actually when I did it, it was a little bit, it was more unpredictable, so I probably did about five cases with it.

And I would say that I was probably happy with three and two I was less happy with. And I’ve kind of found with this, I kind of then didn’t really do it and I felt actually if we do it this way, I feel that we can, we can transfer the information a lot better. And actually I think there is a certain part of it that my eye is now trained to pick up shade very quickly.

So I think it’s just practice. It’s like that whole 10, 000 hour principle, right? It takes time, and now I’m what? Graduated in 2006, and I’m 17 years qualified, and for us GDPs, it takes time. I mean, GDP is the ultimate specialism, right? Being a multi discipline practitioner takes time to hone your skills and shape taking is just another facet of that.

[Jaz]
Very true. I say it’s all time and I’m so glad you echo that there as well. In terms of when you’re doing this, have you gone to a stage now where, you know, what us mere mortals do, I mean, is what we do, is if we’re doing a single central, we will often say, actually, you know what, I’m going to consent you that we might need to do a veneer on the adjacent tooth to, so that we ceramic and ceramic and not tooth and ceramic.

So, really with the way, with how meticulous you are, you’ve got into a situation where you’re probably not doing that, not needing to do that, or is that sometimes still necessary for other reasons?

[Imi]
Jaz never, I’ve never ever done it. I can see where there might be a tendency to do it. I don’t feel that with this protocol I have a need to do it at all, and it hasn’t been necessary, for me it’s unnecessary treatment. I can see if you’ve got a really, if a patient’s asking for it and they want it doing, then I suppose maybe it’s open for discussion, but I tend to get sent cases where I get sent the really, really difficult cases where, people have had very high maintenance patients that have had full mouth rehabs, and where they’ve snapped off due to occlusal issues, or TMJ issues, et cetera, they’ve de coronated a tooth and they need an implant at the front, and, of course, they’re horrified, and yes, it would be easy to say that, oh, I can change all of these things when I’m doing this central incisor.

But actually, for me, there is no need to. I mean, the only challenge in those cases is for me to find out what material has been used, what ingot has been used, because I will always try and match it up. But of course, remember, ingots can be different as well. If one is made three years later. But actually, for me, I just love the challenge of trying to get that single unit correct, and hence why I don’t go down the line of actually restoring other teeth to match into that.

The only time I would touch the adjacent teeth is if I feel that maybe, for a resolution of a black triangle, at the outset I’ve identified that a little bit of bonding needs to be done, then fine, I will tell the patient, when I do the temporary crown, I will do the bonding, so we can have a bit of a trial run and a play with it, and then thereafter, for the final restoration, we’re all good.

[Jaz]
I mean, I look at your stuff on social and I’m already mesmerized by you. And now after having this chat with you, honestly, I am blown away. I’m really inspired. Honestly, I’m super, super inspired. I feel like I tell you how I feel. There used to be a time where I thought I could not go to sleep without having dinner.

I just thought that I can’t sleep without eating something at night. And then a year ago I did this 72 hour fast, I just had water and black coffee. It was to raise money for Ukraine and that kind of stuff. And I did it and I was like, okay, fine, I just need to change my mindset.

And you have completely done that to me, right? I’ve now fasted for three days with you on this topic of, actually I can improve my photos, my communication to nail the shade matching. So next time I’m so excited to use some of this. But there is so much more to it. Like you said, the whole emergence profile, zenith’s and the planning and stuff.

What I want from this episode is to inspire everyone. I’m sure you’ve definitely done that, which is amazing. We’ve picked up a few photography tips. We’ve learned about how meticulous you are, which is brilliant. I want them to learn more from you. Tell me about what kind of courses you do to help people to take the next step.

[Imi]
Yeah. So, I mean, one of the first courses that we launched was a couple of years ago, and that was aesthetic prosthetic. And that is something where we really wanted to create, with Minesh Patel, we wanted to create something that really was brilliant for the up and coming GDP, but also for the experienced implant dentist.

And we really wanted to create a course that focused on implant restoration, but actually to combine it with dental ceramics and discussions about EMACs and zirconia and PFMs and bridges, and essentially taking the aesthetic aspects of all, both of those areas into the restoration of implants and how we make implants look like natural teeth.

So, we run a day course on that, which covers all of those areas. It talks a lot about assessment and planning. It talks about soft tissue a lot, because my love of surgery, everyone knows about, so yes, it’s a restoratively driven course and an aesthetics course, but I cannot help but put at least an hour of soft tissue into that.

So I give a bit of an insight and a bit of an insight into my mindset with regards to connective tissue grafting. and keratinized tissue, and improving pink aesthetics. And that actually is so important for implants, which is what I kind of wanted to get the general population, the general dental population to sort of see.

But actually, to make sure that the GDP that maybe doesn’t really delve too much into implants, could really identify the cases, what would need to happen. And the most simple case is maybe they would be able to refer and then restore. And hopefully some of them in time will be able to surgically manage these cases.

And then of course we kind of brought out a surgical course, where mainly focusing on ridge preservation. And that, for me, is something that I think is very under taught. Because ridge preservation is something that I think every general practitioner should do. Because the resin bonded bridges, which I know you are a big fan of Jaz for me now, for me, for gaps and missing teeth, I can get as good an outcome with a single central incisor implant as a resin bonded bridge.

With rich preservation and perhaps with some soft tissue work. So now missing teeth, I’m 50 percent resin bonded bridges and I’m 50 percent implants, so for me, it’s not, so a lot of my that course, which is 15 C, which people can find on www.15-c.com it talks through a lot of these really nice resin bonded bridge cases.

So it’s kind of driven down that way. But also for patients that what need rich preservation for future implants to simplify treatment, but with a restorative mindset. So all of my stuff is restoratively driven and that really the two courses kind of combine and a sort of early stages in the journey of stuff that I’m hoping to produce.

[Jaz]
I so agree and ridge preservation is something that do you feel that GDP should be able to offer for most routine extractions if the patient’s thinking, hmm, maybe one day I’d like to have an implant? Is that something that you think is a good thing for GDPs to do?

[Imi]
Yeah, I mean, Jaz, I’ll ask you a question. I mean, so when you extract a tooth at six months, how much of the ridge do you think is gone?

[Jaz]
That’s a great question. I think the buccolingually, I think it’s to do with the technique, right? If you’re really atraumatic, natural healing won’t take it too much, but if you lose the buccal plate, you’re screwed. As a statistical answer, I don’t know the answer. I’d love to know, but I do think it has something to do with biotype and the care of the surgeon.

[Imi]
Yeah, I think that has some factors, but if you look at all the systematic reviews, you will see that at six months, the alveolar ridge has resolved by 50%. And with ridge pre- if you look at ridge preservation, then following ridge preservation with the appropriate protocols, you will retain 95 percent of the alveolar ridge. And one of the things that I do with my Ridge Preservation Protocol, I actually do it with an open healing concept, which actually means that the muco gingival junction, or the keratinized tissue, we’re not moving at all, and all you’re doing is you’re growing new soft tissue over the site that you can use for further pink aesthetics later on.

So it’s a very simple protocol. I think really it’s something that I think that all GDP should offer, whether they’re doing bridges or implants. And because it’s, it’s relatively simple to carry out with, with minimal complications.

[Jaz]
Before I publish this podcast, I’m going to book my place so that in case it gets sold out, then I’ll be there. So I’ll see you on that, my friend. That sounds amazing. So I’m looking forward to learning from you and Minesh as well.

[Imi]
No, that’s really kind. We just put out a date for January for 15C and AP, but that sold out. So we’re just gonna look to set up another date, probably in April, end of April, so just look out for that one.

[Jaz]
Amazing. And so the Ridge Preservation one is 15C, yeah?

[Imi]
Ridge Preservation is 15C, and Aesthetic Prosthetic is the implant restoration and dental ceramic one. And usually what we’re doing now, we’re actually doing them as a double header on a Friday and a Saturday. So if people want to come to one, they can do one. If they want to do both, then there’s a discount in doing both of them.

[Jaz]
Amazing. I look forward to putting the links on there. I really want to support what you do. I just, I love the everything that you give and you share. And I think everyone deserves to learn from people like you. And here’s a curveball question.

And if you don’t mind, because we’re at the end now, I know it’s 10 o’clock. A while ago, there was a podcast episode I did with a young producer artist. She did some veneers on a patient and the patient said on the day, Oh my God, these are amazing. These are fantastic. And then the patient comes back and they changed their mind.

I feel as though with the way that you probably talk to your patients, the way you consent them and stuff, this may never happen to you. So what I want to know is, has this scenario happened to you whereby a patient’s gone away seeing really happy and then, you know, beauty is in the eye of the beholder.

They come and their perceptions change. They’re no longer happy with their restorations anymore. Has it happened to you? And B, if it hasn’t happened to you, what advice would you give to someone if it has happened to them?

[Imi]
Yeah, I think, okay, so it’s never happened to me. There have always been, there’s always patients that turn up that you get warning signs about.

Okay, and we’ve always had those warning signs patients, I think in those patients who obviously your consent for your consent process And I’m not talking about a consent form because what is a consent form, you know largely irrelevant and actually it’s just the process that you go through. So usually with this type of patient I know that I’m gonna end up spending a lot more time with them.

Okay a lot more time with them So I will usually factor that into my estimate So, I will factor in the fact that, potentially they might come back, and something might need tweaking, and I might need to change something. So I will allow for that, and I think that’s reasonable and fair to do if someone’s gonna take that much of your time.

I think if the patient is really happy, And everything has been normal throughout treatment, and then a week later, they have a change of mind. Then I think, personally for me, because these cases are few and far between, I would get things sorted for them. You know, for me, as long as I felt that they were being reasonable, number one, number two, as long as I felt that what they were asking for was achievable and I could see what they were seeing, I could feel the same thing.

I could feel that, you know, these edges that they’re talking about or this angle was there, then I think it’s our duty that we put things right for them. I think the risk of not sorting things out for a patient like that is, like they say, you do something good for someone and they will tell x amount of people.

You do something wrong for someone, there’s a problem, they’ll tell a whole load more, right? So, for me, I would be trying to, trying to put that patient right, as long as I had the skill set and I was able to actually do that. Because you don’t want to make the situation worse. You don’t want to make the situation worse. I mean, have you had that happen before to you, Jaz?

[Jaz]
I’m trying to think. I mean, nothing in a big way, no. I’ve never had it in a big way, but you hear about colleagues whereby the patient’s really happy, and then a family member makes a comment. Someone made a comment, or they said something, and suddenly they start doubting it and saying, actually, are they too white?

Are they too white? Whatever. I’ve never had to drool work off or whatnot, but it is something, and I completely agree with you. You get those warning signs, but one rule I implemented, I probably learned this from Lincoln Harris, is when I finish something, whether it’s orthodontics, or a composite case, or a ceramic case, or whatever, I want to be at peace with myself that I like it.

I want to really love and like what I’m seeing in front of me. Because if they come back, and if I notice that actually this tooth is a little bit rotated, and I’ve just finished it, and I haven’t addressed that myself, Then I’ve let myself down and if they come back and say you know what this tooth is rotated I’m like I have no leg to stand on because like yeah, it is.

I’m sorry about that. Let’s do that again So if I’m happy that I’ve been a perfectionist into my own standard and if the patient then says no I don’t want you to correct this. I’m happy. I really need to finish now then fine. But otherwise, I will try to make sure I’ve satisfied my own criteria. I think you know, you’re probably the same as that.

[Imi]
Yeah, I think you’re absolutely right I mean if there is one aspect of dentistry that I struggle with because I don’t do a lot of it. The thing that I get tired at the end of the appointment is if I, if someone pleads with me to do their bonding for them. And when I’m looking at bonding, like, say, four to four and I’ve spent a few hours doing it. At the end of the appointment, my brain is just fried. You know, even halfway through, I get up and I just walk off.

And then I come back and I carry on doing it. And invariably, at the end of the appointment, the patient’s delighted. I’m exhausted and delighted. And we’re happy with the outcome. We have a hug. We send them off. All good. I get home and I blow it up and I’m like, Oh, shit. This is not good enough.

I need to just tweak this. I need to tweak that. I need then I ring the patient the next day. I’m like, you have to come in. You have to come in because I want to change it. And then And they say, Imi, I’m not letting you change it. And I’m like, No, look, really, I need to change this. And that’s the only aspect of my dentistry that I think that because I don’t do a huge amount of composite bonding cases, so I’m not a machine in that way, that I feel, and maybe most people get their patients back for 30 minutes anyway to polish and refine it and to change the angles a little bit, because I think there’s only so much you can do and see in any given time, right? We’re human at the end of the day.

[Jaz]
No, great, great insights, Imi, it’s late at night, we both have wives and children waiting for us, probably the children are in bed now. Thank you so much, man, for giving up your time, I had a great time learning from this, I’m gonna go, I’m gonna troll through your Instagram again, do I have your permission to just put some images from your Instagram profile on this video?

[Imi]
Please, please do. Please do, Jazz. You can share whatever you want. And if you need anything, just ask me and I’ll send it across.

[Jaz]
Amazing. And guys, please, Imi and Minesh are really two wonderful chaps. So we’re lucky for those of you in the UK. We’re really lucky that we have them here as clinicians. Go and learn from them. Show me, show me your support, Protruserati. And thank you again. I can’t wait to put all this in the show notes.

[Imi]
Thanks, Jaz.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening. All the way to the end. If you’re a premium subscriber, then you can get access to the full transcript, PDF and the premium notes.

And also for this episode, we’re going to make like a step by step because Imi gave, you know, he unpacked a lot of information here so we can make a step by step by step as we sometimes do. And they’re usually really well received. So expect that to be. If you’re not already a premium subscriber, this is how you can get CPD for listening all the way to the end, just by answering a few questions.

It costs less than a Nando’s per month, basically, and that’s tax deductible. So if you’d like to join us, head over to protrusive.App website or download it on iOS or Android. For those of you listening on Apple and Spotify, if you haven’t yet given us a rating before, please do that. That’d be really appreciated.

And if you’re on YouTube, please give this a thumbs up to let me know you watched it all the way to the end. I’ve also decided that every episode I want to make a habit of actually thanking the team behind Protrusive. So I’m going to read out all the people who are part of the team who helped to get this done.

So this episode was produced by Erika Allen Benitez, my producer. The images and graphics were prepared by Mari Benitez, and the premium notes for premium subscribers, as well as the step by step, was created by Emma Hutchison, all the way in sunny Scotland. Thanks again, and see you same time, same place next week.