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Dental Ceramics for Absolute Beginners – PS013

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Контент предоставлен Jaz Gulati. Весь контент подкастов, включая эпизоды, графику и описания подкастов, загружается и предоставляется непосредственно компанией Jaz Gulati или ее партнером по платформе подкастов. Если вы считаете, что кто-то использует вашу работу, защищенную авторским правом, без вашего разрешения, вы можете выполнить процедуру, описанную здесь https://ru.player.fm/legal.

What influences your decision when choosing ceramics?

What are the main ceramics nowadays—and do porcelain-fused-to-metal still have a place in dentistry?

Are the protocols different for various types of ceramics and crown materials?

How important is rubber dam isolation, and is a split dam good enough?

In this Back to Basics Protrusive episode, Jaz teams up again with Emma Hutchison, ‘the Protrusive Student’, to break down these critical questions and simplify the world of ceramics. From decision-making frameworks to practical rubber dam tips, this episode is packed with insights to elevate your practice.

Whether you’re a student navigating the foundations or a seasoned clinician revisiting the essentials, this discussion offers a fresh, evidence-based perspective on mastering ceramics in dentistry.

Watch PS013 on Youtube

Key Takeaways:

  • Understanding the role of metal ceramic crowns is crucial in modern dentistry.
  • Monolithic ceramics are preferred for posterior restorations due to their strength.
  • Layered ceramics can enhance aesthetics but may compromise strength.
  • Proper crown preparation is essential for successful restorations.
  • Communication with lab technicians is vital for successful bonding.
  • The choice of ceramic material largely depends on the amount of enamel available.
  • Following manufacturer protocols is key to achieving optimal results.
  • Bruxism patients require careful consideration in material selection.
  • Rubber dam isolation is crucial for predictable bonding.
  • Digital scanning requires more aggressive tissue management.
  • Impressions are still valuable, but digital methods are advancing.

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

Highlights for this episode:

  • 03:52 Emma’s Exam Experience
  • 07:28 Feedback on Previous Episode
  • 08:00 Discussion on Ceramics in Dentistry
  • 10:51 Practical Applications and Material Choices
  • 19:45 Monolithic vs. Layered Ceramics
  • 24:18 Exploring Milled Cobalt Chromes and Gold Crowns
  • 26:14 Challenges in Fitting Restorations and Bonding Techniques
  • 30:03 Rubber Dam Techniques and Benefits
  • 37:01 Intraoral Scanners vs. Traditional Impressions
  • 40:14 Effective Communication with Lab Technicians
  • 44:25 Conclusion and Future Plans

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 010 BASIC SCIENCE (Dental materials)

Dentists will be able to –

  1. Identify the suitability of ceramics based on their strength, aesthetics, and application.
  2. Highlight the importance of proper crown preparation and manufacturer protocols for optimal results.
  3. Emphasize the importance of rubber dam isolation and compare the benefits and challenges of analog impressions versus digital scanning.

If you love this episode, make sure to watch Composite vs Ceramic with Dr Chris Orr – PDP030 and make sure to read the Protrusive Notes!

Click below for full episode transcript:

Teaser: I do not place lithium disilicate and I cement it. So for me, the way my mind works is if I'm cementing and not bonding, if I'm cementing just using a GIC based cement, so I'm not relying on enamel for adhesion, why would I use lithium disilicate? Using lithium disilicate posteriorly and bonding it, excellent strength, good, it's going to be fine, as long as you give it enough thickness, 1.5-2mm, you're golden, okay.

Teaser:
If you don’t respect the thickness, or if you use cement and you don’t bond it, you’re going to really compromise on the strength, you’re not going to get the high strength. So therefore, the same material, lithium disilicate, cemented is a completely different ceramic to the same ceramic lithium disilicate, bonded.

You need to know your material and the correct protocol for your material. You’re not supposed to air abrade lithium disilicate. But I know some clinicians who whatever material they get back from the lab they will air abrade it. You do introduce micro cracks. Whether it or not it’s clinically significant or not, I don’t know, but I’m one of those people that I follow the rulebook for any material I use, any bond I use, like exactly how the manufacturer wanted it, I pretty much will follow that.

The other thing to bear in mind is, how important is it to you that this molar tooth, looks absolutely gorgeous. How important is it to you? And I wait for them to say the answer. Okay, and I say, okay, you want it to look gorgeous, but what if I told you that if you accept that it’s going to look good, but not gorgeous, it will last way longer because the chance of it breaking is way less. What’s more important to you? Longevity or beauty?

Jaz’s Introduction:
When I was a student, like many things, ceramics were very confusing. And fast forward many years, when I qualified, they were still very confusing. What I present today in this back to basics series with Emma Hutchison, the Protrusive Student, is a simplified overview of ceramics and how I view them.

My views are based on the courses that I’ve been on, the evidence that I’ve read, and my daily clinical practice, which makes up a third of evidence based dentistry itself. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Hey, the last one on extractions. I mean, you guys loved it.

So thank you so much for everyone who liked it and commented. It really helps us to keep going. I was always unsure about this Protrusive Student series and going back to basics, but you guys are loving it. And I really appreciate that. I mean, Emma will continue to make dentistry tangible for students, but a lot of these episodes are very useful for dentists, like a back to basics, revisiting the foundations.

There’s something very validating about that. Sometimes you can only measure your growth when you look back and listen to an episode like this and feel that, you know what? I knew kind of everything and look how much I have grown. There’s a real beauty in that. So in this episode, we cover decision making in ceramics.

What influences your decision. What are the main ceramics that I’m using nowadays and do I still use porcelain fused to metal? Are the protocols different for the different types of ceramics and crown materials? How important is rubber dam isolation? Is split dam good enough? And we’ve even thrown in some rubber dam tips in there for you.

This episode, like the last one, is eligible for CE. Protrusive education is a PACE approved provider. And we also satisfy the criteria for the GDC. All you have to do to play and collect CPD is answer the five questions and get 80%. That’s only available on www. protrusive. app. Once you make an account, you can download it on Android and iOS, listen on the go, answer the questions, also answer the questions of the past episodes that you’ve listened to, and validate your learning.

An opportunity to reflect, which forms part of your personal development plan. We’ve also got the notes from this episode written by Emma, all about dental ceramics, like a cheat sheet for any student. It does go quite deep, but it’s all the stuff that you need for your exams. And that’s in the crush your exam section of Protrusive Guidance.

Once you join Protrusive Guidance, you just have to email student@protrusive.co.Uk so we can verify you’re a student and add you on there. Now let’s join the main episode and I’ll catch you in the outro.

Main Episode:
Emma Hutchison, the Protrusive Student, welcome back. You’ve just had an exam. How did it go?

[Emma]
It was okay. It was a structured clinical reasoning exam. And which was something that, it’s something that Glasgow only introduced. I think two years ago, it might’ve been last year, actually. So no one really knows what was going on. So.

[Jaz]
An example question from there that was a tough one.

[Emma]
Yeah, so you’re basically given a few cases, and you have like an assimilation time to sit in a room and look over these cases. You just get radiographs, clinical photographs, a bit about medical, social history. So you have 25 minutes per case to read over. You don’t know what questions you’re going to be asked, and then you go in, and you’ve got, for each station you’ve got two tutors or clinicians, and you sit in front of them, very closely actually, I thought they were going to be a bit further away across the room, but you were sitting right in front of them, and they just kind of grill you on your treatment plan.

If it’s oral medicine, they’ll ask you questions about histology, things about medications as well. Like, we had a patient that was on Warfarin, so they’re going to ask about all the INR, things like that.

[Jaz]
You knew that. You knew all that, right?

[Emma]
Yeah, yeah. It’s just hard because you have no idea what’s going to come up. So, a lot of it is reading over your guidelines, SDCEP, American Endodontics, things like that. So, it’s very intense. It’s very intense, but I’m glad it’s over.

[Jaz]
Which was the question that stumped you?

[Emma]
So, you get your topics two weeks in advance, so we were restorative and orthodontics as well. And for restorative, I thought I was going to completely fumble because it is such a huge topic with ortho at my level.

In dental school, there’s only so much that they can ask you, I suppose. But the ortho one was really, really tricky. They wanted very specific answers. It was kind of good cop, bad cop. It was very intense.

[Jaz]
It was all surrounding that specific case that they gave you, right?

[Emma]
Yeah, yeah, so we had a case of a little boy who was like class three. You had to go over all the treatment plans which, in theory I do know, but it was quite intense. But everyone in my year sort of felt the same, so we’ll see how it goes.

[Jaz]
With dental exams I couldn’t read it when I came out like, when I did maths, back in the day, in A level maths, right, I was pretty good at maths, when I wanted to be.

Like, I went into my C4 last exam knowing that all I needed was 13% to get my A. That was the highest grade at the time, they’ve got like A star or whatever now in A levels, but I needed 13%, right? So, I completely didn’t study C4 at all. I just knew that I can just get a 13% like by writing my name.

So I’ve got like 55 in that. And everything else I’ve got like 99 and 100s, basically. So I was, when I was wanting to be, I knew I could switch it on for maths. And then, so when I come out of maths exam, I knew, okay, I’ve aced it or I flunked it. I knew, right. When it came to dental school, I was like, I had no idea, especially with those kind, when you’re being interviewed and OSCE’d. And sometimes I come out and think, Oh my God, I flunked this. And then I surprise myself. Like, it’s difficult to read.

[Emma]
Yeah, it’s really difficult to read. And they said we had a sort of recap of it and they were saying, you know, we did purposefully examine it a bit harder because when it comes to our case pres, and we’ve got another clinical reasoning exam later on in the year. I don’t know, they wanted to give us a bit of a fright, I suppose. They said in hopes that the real thing, the big, big exams that are a lot more heavily weighted, will be a bit nicer.

[Jaz]
It’s a good approach. They give you a real tough time so that the actual thing will be easier and nicer, so that’s good. Well, today’s topic is ceramics. Our last episode, Extractions, went down really well. Everyone loved it, so well done Emma. It was great questions that you’d asked. Everyone loved the avocado analogy, but more importantly, did you resonate that analogy? Have you done an extraction since? Maybe you haven’t, I don’t know. You tell me.

[Emma]
You know, I actually haven’t done an extraction since I was on a good roll with extractions and now it’s completely stopped. So hopefully in the new year.

[Jaz]
But right now, you know what an application point feels like now you know to liken it like an avocado and stuff and then the removal of a nut. So that was good. I enjoyed that very much. And today’s ceramics, right? So ceramics was a topic that again, I mean, so many topics at dental school confuse you, mostly do. But this is in materials. Like I was okay at memorizing about leucite reinforced and then the history of ceramics and stuff.

But at the actual practical element of delivering ceramics and actually, what do you actually do in the real world? I had no idea. Like really, it was very heavily, heavily emphasis on PFMs. Like your exam was a PFM, porcelain infused to metal or metal MCC metal ceramic crown, as some people call it. And so, I’ve hardly done many since qualifying of those crowns.

Yeah, I still do. And we’ll talk about the indication for that. But nowadays in a world of all ceramic, what I was being taught was already quite outdated. So I’d be interested to know. What kind of crown preparations are you being taught? What kind of materials are you being taught to use on your patients?

[Emma]
Yeah, so I think in Glasgow, we’re still learning about metal ceramic crowns, how to prep them, but we are also learning about all ceramic alternatives, I suppose. So my first question was going to be about, do metal ceramic crowns still have a role in dentistry today? Like, especially in private dentistry, I wonder. Or have they largely been replaced by all ceramic?

[Jaz]
The answer is they’ve largely been replaced, but they still have a role. To get PFMs, like, working well, right, and looking good, you need space. You need that 1. 5 to even 1. 7 millimetre, if you’re making it look really aesthetic, right? So you have the metal layer, the opaque to block the metal layer.

Then the ceramic and to actually give it a good bulk to make it look pretty. It needs a lot of space. And so that ends up being a very invasive preparation. We’re trying to move away from that. So to do a proper PFM that looks good, it still has a place, but maybe not so much. And so the time that I would use it and a lot of today is very much, if you had a different podcast host, you’d be getting different answers.

So a lot of it is based on my opinions and experiences, and everyone’s, I think, everyone’s got a story, everyone’s got experiences that have shaped them, that shape their thinking. So for me, the time I use PFM nowadays is, if I’ve got a severe, high force, bruxist patient, and I would like to have a metal occlusal.

Because it’s got very good wear properties. It’s got very good strength and longevity. I can be more conservative by having metal only, right? So I don’t have to drill as much. But then maybe on the facial, I’m not going to go for a super aesthetic. Maybe it’s a first molar, maybe it’s a second premolar.

And so I’m still going to be a minimal prep and accept that it’s going to be an ugly looking PFM. Like, only the buccal will have porcelain, but it’ll be a very thin porcelain, and it won’t be very aesthetic, but for this more functional tooth wear case, it’s going to be completely adequate. So that’s where I’m using it at the moment, whereas we’ve pretty much moved to zirconia and lithium disilicate, which are the two main types of ceramics.

[Emma]
Yeah, yeah. So another question that I did have was, what factors determine your choice of ceramic material for I’m going to say largely for posterior versus anterior restorations.

[Jaz]
Okay. It’s very simple and it doesn’t change so much depending on anterior versus posterior for me.

[Emma]
Okay.

[Jaz]
Okay. So put it this way. If I know that I need to go indirect. So I’ve decided, and so again, recap a little bit. For posterior, you know that it’s too ambitious to go direct here. You’re literally having to do an MODBL. You’re going to find it difficult to get good contact points. Maybe the tooth is root filled and you need to cover over the cusps so that the cusps don’t bend and flex and break.

So there’s so many good reasons sometimes to go indirect. So, when we made that decision that we’re going indirect posteriorly, if I’ve got enamel, all the way around, I’ve got a decent amount of enamel and the tooth isn’t so destroyed. It’s still got some enamel to bond to. My substrate to bond to is good. I will go for a bondable partial coverage restoration. So do you know what I mean by partial coverage?

[Emma]
Like an inlay or an onlay?

[Jaz]
Yeah. Not so much inlay in this scenario. I’m talking about an inlay is basically you could have done the DO composite, but you asked the lab to do it instead of you. That’s essentially an inlay. Right? The onlay more like covering over the, like an overlay.

You’re covering over the cusps. And you’re bonding to the enamel. The ceramic, etchable ceramic, which you talk about, okay, lithium disilicate, right? I will go lithium disilicate because it’s conservative. Why should I have to remove any tooth structure that I don’t have to? If I can bond to the ceramic, it has no retention form.

It’s got a tiny, teeny bit of resistance form. We’ll talk about that. But I’m relying on the quality of the enamel for my bonding. It’s very conservative. You literally, all you have to do is remove the old MOD amalgam. Take the cusps down a couple of millimetres and that’s your prep pretty much done.

You just smooth it and you block out the undercuts with composite. So the prep is enjoyable. You feel like you’re saving so much tooth structure. And if I’ve got enamel, I will use lithium disilicate. Why lithium disilicate? Because it’s got very predictable bond. I will not use zirconia partial coverage restorations, even though nowadays some clinicians are.

And I’ve asked this to real top dogs, okay? I’ve asked this to Dr. Nasser Baghi in 2018, is a top dog in the US on zirconias and ceramics. Recently, where was I? I asked Chris Orr this question at BACD just this year, 2024. And I said, when these zirconia restorations are showing such promising data that we can bond to them, should we be moving away from lithium disilicate?

He’s like, no, we have this beautiful material, lithium disilicate, that’s predictable and it’s got so many advantages. Let’s just stick to this. I mean, he’s not yet moving on to zirconia posteriorly. If posterior and has good enamel, I’m going Emax, which Emax is a brand by the way, it’s a brand of lithium disilicates by Ivoclar.

Okay. The other one is LiSi by GC. So they are both examples of lithium disilicate. Now that same molar that has got less enamel, maybe the mesial and distal caries is really deep and you’re on dentine now. And you have just generally less tooth structure. I’m instead going to go to for zirconia, I’m going to go a full crown all the way around 360 degrees and I will prepare and this might blow your mind as a student, but something called a vertical preparation. Now being the Protrusive Student you have access to all my webinars.

You have access to everything. You should eventually do VertiPrep for Plonkers. It’s something that teaches everyone to do their first vertical crown, but essentially there is no shoulder. There is no chamfer. You’ve hardly drilled into the tooth. It is a super conservative way to deliver a crown in a really lovely conservative way.

So I’m getting all the benefits of having retention and resistance, but I’m not sacrificing much more tooth structure to get that. So if posterior is either lithium disilicate, if I have enamel, or zirconia, if I don’t have enamel. And then, like I said, in that severe bruxist patient, if I want metal occlusal, I might go PFM, but that’s rare. Any questions on that before I move to anterior?

[Emma]
No, it’s a different take to what we’ve been taught at uni, but it’s interesting, like, it makes sense.

[Jaz]
What have you been taught at uni? I’d love to know.

[Emma]
So a lot of the things we talk about at uni are purely based on like strength and aesthetics and how certain ceramics are better anteriorly because they’ve got good aesthetics but then posteriorly you want to use something else because they’re stronger, they’re more robust.

[Jaz]
Can you give examples? Do you remember the names of ceramics? Can you give some examples?

[Emma]
Is it lithium disilicate?

[Jaz]
Don’t worry if you don’t remember. It’s okay. I hardly knew anything about ceramics when I was at your age. It’s great already.

[Emma]
Is it lithium disilicate that’s better for like translucency in the interior or have I got that the wrong way around?

[Jaz]
No, no, it’s got the different ingot types basically. So it’s like high translucent, low translucent. So yes, lithium disilicates can be quite nice looking. A lot of veneers are done in this type of material, but it is totally appropriate to use posteriorly as well. Let me say again, it is totally appropriate. And here’s the magic bit.

Now, the most, probably the most important part of this podcast will be this, providing you have enamel because if you have enamel, you can bond. What I don’t do is I do not place lithium disilicate and I don’t cement it. So for me, the way my mind works is if I’m cementing and not bonding, if I’m cementing, just using a GIC based cement, so I’m not relying on enamel for adhesion, why would I use lithium disilicate?

Do you know why? Do you know why I’m against using lithium disilicate? The magic property of lithium disilicate and feldspathic porcelain veneers, the magic of what happens when we bond them.

[Emma]
No.

[Jaz]
And that’s totally fine. I wouldn’t have known at your stage, but the main lesson here is feldspathic is a type of ceramic, basically. It’s a very beautiful ceramic traditionally used for veneers. Not so much anymore because the number of technicians who are skilled at this is less and less and less as we’re getting more CAD cam and whatnot, and then labs are getting more digital, but essentially these veneers are beautiful. But they are weak.

Something from my mind, I remember like 90 megapascals, let’s say, right? So they are weak compared to 250, 300 megapascals of lithium disilicate. So they’re weak, but they’re beautiful. But once you bond them to enamel, they are so strong. It’s a bit like a tile, a glass tile. If you drop the tile, it’s going to break.

If you actually glue that tile on the floor, it is strong. That was the analogy that was given to me when I was a student. I still remember this basically. So using lithium disilicate posteriorly and bonding it excellent strength. Good. It’s going to be fine. As long as you give it enough thickness, 1. 5, two millimeters, you’re golden.

Okay. If you don’t respect the thickness. Or, if you use cement and you don’t bond it, you’re going to really compromise on the strength, you’re not going to get the high strength. So therefore, the same material, lithium disilicate, cemented, is a completely different ceramic to the same ceramic lithium disilicate, bonded.

[Emma]
Yeah, okay. I didn’t know that. I’d never, like, it probably has come up in lectures before, but it’s not something that I’ve ever really thought of.

[Jaz]
So that’s why I don’t do lithium disilicate cement, because I’ve got this wonderful material, super strong, called zirconia, and that is really amenable to cementing, and I can get my retention resistance form, because I’ve decided I don’t have much enamel here. So I’ll do a vertical preparation crown posteriorly using zirconia, which I’m going to cement. You could be fancy and bond it, but why complicate the protocol?

[Emma]
Yeah, that’s true. No, that makes sense actually. Think about it. I’ve never heard the analogy with the tiles as well and how it’s a totally different thing once it’s actually glued onto the wall or the floor.

[Jaz]
They behave differently. But I mean, the other key lesson here is giving enough occlusal clearance. So the biggest mistake we make when giving occlusal clearance is A, we don’t give enough. And we think we’ve given enough, and he gets a lab, and they’re kind of literally squashing and squeezing this material in, okay?

And, I don’t know why dentists are so afraid, myself included, back in the day, trying to be as conservative as possible, occlusally. Yes, it’s good to be conservative, but with a lot of these broken down teeth, the occlusal part is like composite. The tooth is lower down, right? So, I’m happy to sacrifice more tooth structure, have a more thickness of crown material that will really make it unbreakable.

So, just remember that. And the common place that we will under reduce is the fissure. The actual fissure itself, okay, is the most likely area that will be under reduced. And the other common mistake is, let’s say you’re doing a pre molar crown, right? And what you do is you end up flattening the occlusal.

You don’t follow the same anatomy, right? You see like the cuspal anatomy, basically it goes rise and fall and rise. If you don’t respect that and you flatten it, great. The cusps have been reduced nicely, but that middle portion, you’ve hardly reduced it. And that’s a big technicians. That’s the biggest issue they have.

So remember when you’re doing the occlusal reduction, follow the anatomical form of the tooth. So it’s a uniform reduction, and then you’re going to get enough thickness where it matters. ‘Cause that’s where the fossa of the tooth is, that’s where the opposing cusp will put the occlusal load down.

So if you want ceramics, that’s not going to fracture. You’ve gotta do that. The other thing, which we haven’t talked about, which you’re probably going to ask about anyway, but do you know the difference between something called like, what I mean when I say the term monolithic, and when I say layered, do you know the meaning of this?

[Emma]
Is this the way that it’s like milled or put together or constructed?

[Jaz]
Not quite, like once you have that lithium disilicate, right, that block is ready to go on, right, there’s two ways to treat it. One is you accept it how it is. And it’s a really strong material. But it’s not as beautiful as it could be.

We can make this. So let’s talk about an anterior crown, right? So if we’re going to do a lithium disilicate upper right central crown, central incisor crown in lithium disilicate, if you have a monolithic, which means that it’s just the pure lithium disilicate material, that kind of like a one shade.

It’s got some transparency, but it is like the one bulk basically. Versus the same crown. But what you do now is you shave the buccal of the crown down a bit by 0. 5 millimeters, for example. And then you add some beautiful weaker ceramic on layer it. You put these effects in.

Okay. That second one, that layered porcelain fuse on top of it, basically. It’s going to look so much more beautiful. We’re going to put those effects in. It’s going to look gorgeous. But it’s now weaker because now you have an interface between the monolithic ceramic and the layered ceramic. And therefore another golden rule here is why would you do a layered ceramic posteriorly?

Why? Don’t do it. The reason why zirconia had a bad rap initially, and also Emax, lithium disilicate had a bad rap initially. It’s because dentists were doing these gorgeous restorations posteriorly and they were layered. So they were actually putting this beautiful weaker ceramic in the occlusal loading area and guess what was chipping? It was delaminating, it was chipping away. A bit like, maybe you’ve seen this Emma, have you seen PFMs where the porcelain’s broken away and the metal’s left behind?

[Emma]
I’ve never seen it, no, but yeah it can happen.

[Jaz]
Not even as your role as a nurse? Do you remember not seeing it as a nurse maybe?

[Emma]
Not that I can remember, no, not that I can remember.

[Jaz]
Fine, so it’s the same thing, like, ceramic is bonded to the metal. In the same way the beautiful ceramic is bonded to the monolithic stronger form, basically. So anteriorly for some patients who are high force, maybe they’re bruxist, you can still do a monolithic Emax or monolithic lithium disilicate. It’ll still look good.

Maybe a 7 out 10 before an aim for a 9 out of 10 plus. You want that same ceramic, but you want it layered, basically. And so that’s the difference. So anteriors tend to layer. For most patients posterior, monolithic. Even when it comes to zirconia, you know? Yes. The downside is they look very opaque.

They look a bit too white, right? But it really depends. It’s a conversation I have my patients. How important is it to you that this molar tooth right looks absolutely gorgeous? How important is to you? And I wait for them to say the answer. And I say, okay, you want to look gorgeous, but what if I told you, if you accept that it’s going to look good but not gorgeous, it will last way longer because the chance of it breaking is way less. What’s more important to you longevity or beauty? And you can’t have both sometimes. And let the patient decide. Because that is then the ultimate level of consent.

[Emma]
Yeah, and would that still be your same protocol for patients that are heavy bruxists?

[Jaz]
Okay, so heavy bruxists. So let’s say that I’m treating heavy bruxists basically, some schools of thought say that because you’re treating heavy bruxists like your molars which take the highest force because remember the masseter muscle is right there, right?

The medial pterygoid muscle is right there. It’s right by the joint. So the forces felt in the molar region are significantly higher than the forces felt on the anterior region. So then people say oh do gold on the second molars, right do gold restorations. They’re longer lasting the more forgiving or maybe do a milled cobalt chrome something metal is considerable. And I get that but the studies would say that as long as you give your ceramic enough thickness, it will fare well, even in bruxist.

And another thing with bruxist is that if it’s a true pathological bruxist, then you, they spend all that money, you want to protect it with an appliance. Things will just last longer. It’s something that we need to accept that. Okay, some patients will need protecting. But when it comes, even without protection, you give enough thickness, the ceramics will survive. But again, posteriors, I will go monolithic. I will not layer. As I say, no need to layer, especially on a bruxist.

[Emma]
Yeah. Yeah.

[Jaz]
You’re just asking for trouble. You’re asking for things flaking and breaking away.

[Emma]
No, that makes sense. And that’s largely what we’ve been taught at Glasgow as well. We’ve went over gold crowns and things like that, but not in too much depth really. But no, that definitely makes sense.

[Jaz]
The last time I did a gold crown on a second molar, guess how much the lab bill was?

[Emma]
Cool. I don’t know.

[Jaz]
It was like 400 pounds. Absolutely crazy. Like the price of gold is so high. And so I went to a British Society of Restorative Dentistry lecture once and there’s a chap, I think his name was Phil Taylor. I think I might be getting it wrong here. And he was a restorative consultant and he suggested that long time ago, he moved away from gold because of the cost reasons to a very good alternative, which is a milled cobalt chrome. And chrome is very kind to enamel. It is stronger and more rigid than gold, which actually is a negative property.

The strength of gold that is because it’s softer, it adapts nicely to the opposing dentition. Whereas the cobalt chrome is you have to get the occlusion a bit more spot on. It’s a bit less forgiving, but it is a very good long lasting, and you can still be very minimal in your prep basically. So I have been doing a lot of milled cobalt chromes when I want to do metal in the posterior.

[Emma]
Yeah, I’ve never heard of that. The milled cobalt chromes before actually. But is there a lot of labs that still do like gold crowns? Like they’re definitely still out there, but.

[Jaz]
Yeah, oh, they’re definitely out there. But be prepared for a, be prepared to prep as minimally as possible. Otherwise the lab bill will be crazy. So add more core, make sure you max out on the core and then prep back to do the bare minimum basically. But jokes aside, the labs will do it. Still fantastic restoration, right? And a lot of dentists will, when in a dentist in their 50s and 60s, when they need a crown, that busted molar, they will ask for gold.

They will ask for a three quarter gold crown or whatever. It’s a beautiful material. And what really inspired me to get into tooth wear was looking in someone’s mouth once. And I was a fine year dental student and just seeing this beautiful posterior gold work. And that really inspired me to go more to restorative.

[Emma]
My next question was about challenges when we’re fitting these types of restorations. So what are like the most common challenges and how do you overcome them? Because I know in practice, I’ve never done direct restorations myself yet. Hopefully soon. Indirect, sorry. Am I getting that right?

[Jaz]
Yes, so things that are made outside the mouth are put on.

[Emma]
Yeah, yeah, so I’ve not done any indirect restorations yet, but I know in practice like I’ve seen etching with acid and air abrasion, like are these necessary steps or are these steps that only some people will take in order to help prevent challenges?

[Jaz]
Okay, excellent question, okay, and you need to know your material. You need to know your material and the correct protocol for your material. You’re not supposed to air abrade lithium disilicate, but I know some clinicians who wherever material they get back from the lab they will air abrade it. You do introduce micro cracks. Whether it or not is clinically significant or not, I don’t know, but I’m one of those people that I follow the rulebook for any material I use, any bond I use, like exactly how the manufacturer wanted it, I pretty much will follow that.

The other thing to bear in mind is you need to have the right tools in your clinic to be able to follow those rules. So for example, if you are going to do a resin bonded bridge, or maybe even a zirconia resin bonded bridge, okay, and these for something like lateral incisors, in the right case, they last so well.

The Matthias Kern data is brilliant, but you need to follow the APC protocol, which means you do air particle abrasion. Use a zirconia primer. So if you don’t have a zirconia primer, don’t even bother doing this. Okay. And you use a composite resin cement, basically. And so you need to follow to get the success that you see in the papers.

You need to follow the protocol exactly. So the most common mistake I see is lithium disilicate restorations. The dentist doesn’t know if the lab has etched it with hydrofluoric acid or not. They don’t know. And then they are either just thinking, Oh, the lab did it and I’m not going to do it.

So maybe it’s never been etched. And the whole way that the lithium disilicate bonds to the enamel is because you want this like tiny little porosities in there to kind of like etched enamel, right? You want the ceramic to actually give you that bond strength. So you need to work with your ceramic properly.

So speak to your lab technician, find out who’s taking care of the etching. Once you’ve done the etching, you want to make sure you’re not air abrading something like lithium disilicate, and then you’re following your bonding protocol to a T. When I’m doing my vertical zirconia because I’m not bonding. We call it plonking.

We’re plonking this on. It’s so easy. Cut on a roll. Dry the tooth a bit, but I use something called IO clean to clean out the ceramic, but that’s not so important. So I’ve got my nice clean zirconia. I’m justly putting some cement inside. I’m plonking it on my thumb. It is so easy as long as there’s no bleeding and I think it is so, so easy when I’m doing a lithium disilicate, I’ve got rubber dam on.

No compromise. Rubber dam has to be on, okay? You’ve got to make sure that you can access the margins beautifully. I got PTFE tape on the adjacent teeth, make sure I don’t get any etch on the adjacent teeth. I’m following everything. You’re preparing the ceramic in a certain way, including the silane. You’re preparing the tooth in a certain way.

You’re air abrading. You’re making sure the air abrasion doesn’t touch the adjacent teeth, otherwise they’re going to stain in the future, all these things. So bonding is more technique sensitive. More can go wrong, but if you follow the steps properly, it’s incredibly predictable and it’s a very fun appointment.

I love both. I love both plonking my zirconia crowns. And also love spending a bit more time. So zirconia crown is half an hour for a lithium disilicate. Overlay restoration is 45 minutes to account for the extra steps, treating the ceramic, the rubber dam isolation. And so the main answer here is know your material, know the best way to treat it. Make sure you’ve had a conversation with the lab to know how they are treating it. And therefore there’s no confusion and you can follow the right protocol.

[Emma]
Yeah, definitely.

[Jaz]
Is there anything about a specific protocol that you want to know, or?

[Emma]
One question I did have actually, see when you’re saying you’ve got rubber dam on in that scenario, what teeth are you, like, is this like a split dam? I’ve just never seen this before in practice when someone’s got rubber dam on when they’re cementing a crown or bonding a crown, whatever. I’ve never seen that before. Like, are you doing a split dam? What teeth are you bringing through, like?

[Jaz]
Okay. Good question. Okay. So some colleagues would say that split dam is absolutely fine because then what you’re kind of reducing is you’re reducing that mouth breathing element of the patient. So split dam’s good, but I don’t see the point of split dam for most cases, because the gingiva is still there poking out. And if you’ve got like most of the times when I’m replacing these MOD amalgams, I’m doing these ceramic overlays. You’re literally equigingival or very slightly subgingival.

And so if you’re using a split dam, your papillae are just contacting your margins or there’s a fluid, a gingival crevicular fluid or sometimes blood. So I’m not a fan personally of split dam when it comes to bonding of my overlays. And what I will do is I’ll do a quadrant isolation. So if I’m doing a first molar, I will do a quadrant.

So maybe something like an upper lateral all the way to the second molar. I’ll make sure I’ve rehearsed the restoration when the rubber dam is on to make sure I’ve got a nice path of insertion, I can seat it, I can locate it well. I’m then following all the steps for getting the onlay ready, the overlay ready.

I’m following all the steps to get the tooth clean and ready. And then, while the rubber dam is on, and what the rubber dam does, it suppresses your papillae. Now, you can see clearly, you can walk a probe around your margins, okay? And it also makes it clean up easier as well, basically. Because then you’re not, as soon as you start cleaning up, you poke the gum, it’s going to start bleeding.

The rubber dam will protect you. It’ll give you some protection basically. So I’m not a big fan of split dam when it comes to bonding my ceramics. Remember Emma, you’ve got access to all of this and those dentists who are listening, watching, I’ve got example videos of through, POV, point of view.

I’ve got my loop camera on. I’m bonding these lithium disilicates exactly how Emma’s described on the rubber dam. So I’ve got all those videos in the Premium Clinical Video Section of Protrusive Guidance, so do check those out guys.

[Emma]
I think a lot of students can get quite frustrated with rubber dam and I think it’s because we’ve not yet seen the benefit that it can have, you know, we’ve not been doing this long enough to see the failures when you don’t use it.

[Jaz]
Oh Emma, when I was in third year, I remember being in a locker room and there was a dentist, I’ll name him Michael Spencer, with me and him I just, I remember him being there in the locker room and I said to him, when I’m at dental school, I’m never going to use rubber dam. I said, cut and roll all the way.

I said that to him. And now like, although I’ve relaxed in the last couple, I was like very much rubber dam police before I’ve relaxed a bit because I’ve now found like greater curve matrix, which gives such a wonderful seal that I need it less and less. So as long as the patient’s not a mouth breather and it’s the upper tooth.

I can pretty much do a lot of it using a nice metal shield, basically, as long as a mouth breather. If I’m working on the lower arch, I’m pretty much always using rubber dam. That’s my recipe at the moment. And for me, Emma, it’s like, forget the increased bond strength. Forget the risk of contamination.

Forget the access to the margins and suppressing the papillae. The main benefit of rubber dam for me is relaxation. That rubber dam is on, the patient can’t speak. Amazing. Fantastic. Rubber dam is on. Okay. And I can turn away and know that I can sleep well at night knowing that no one licked anything.

I can drop my onlay and it’s fine. It’s because the rubber dam is going to catch it. Comfort for the patient I think is good. I just find it’s a happy place to be. Rubber dam is on. It’s just a beautiful, happy zen zone, that’s my number one benefit. It’s very selfish. I use rubber dam because it reduces my stress.

[Emma]
No, the few times that I’ve placed rubber dam as well, like it’s very, very frustrating. Like I’m not good at it, but once you saw it.

[Jaz]
You’re not good at it because you haven’t done it enough. And you’re probably using the crappiest dam in the world, the green one. Right?

[Emma]
I think for, we actually do have the thick blue ones in the dental hospital, or they give us that for OSCE’s anyway.

[Jaz]
Well, okay. Again, so posterior, and again, everyone’s different with what they recommend. And for me, posteriors, I like to go medium thickness. Anteriors I go heavy. Because anteriors often you want to suppress the papilla a lot because you’re doing like bonding and stuff, that kind of stuff. Whereas posterior is you want it easy to go on. Right? So medium is a thinner. So, when I was learning, I was using that horrible green dam, right?

[Emma]
Yeah. I know the one you’re talking about.

[Jaz]
And the other terrible ones, that purple one, that ribbed purple one, they call that the devil’s condom. You punch one hole. You punch one rubber dam hole in it and you put it over your head. I think someone called a John Cowie, the Endo Chap in Bristol, mentioned from Instagram, it’s hilarious. You put one hole in it and you can literally poke your head through one hole and it’s just a nasty rubber dam.

Okay. And so really you want to go something like nictone. I love the unodent stuff, just some thin stuff that doesn’t tear. It greatly, you know, the right tools, the right job. It greatly improves your stress. It reduces your frustration when rubber dam becomes easier. Once you’ve got a system of doing it.

For example, I find that dentists, when they’re struggling rubber dam, they’re trying to do too much themselves. When I’m doing rubber dam, it’s a four handed job. Once I’ve got it over my clamp, I’m just setting in place. My nurse Zoe, she knows she’s going to get a floss set out. Floss set, not floss because guess what?

All of my nurses have got fat fingers and they struggle to floss my patient’s teeth. So you give them a floss set. And they can easily just go through and take that rubber dam with it, basically. Okay? I joke about the fat fingers. They struggle, right? There’s four hands in there. It’s difficult to get a floss set in. You remove the hand out of the equation.

[Emma]
Yeah. And I’ve never seen anyone do that. Like, I struggle so much. You feel so silly as the nurse as well. Like trying to floss that through. You’re like, I know how to floss, but it’s, it’s really, really difficult.

[Jaz]
Angulation and everything’s different. But when you use it, it’s so much easier.

[Emma]
Yeah. Yeah. And we use the, it’s the unodent one that we have at uni as well. I think we used to have the purple one before, but it just wasn’t good.

[Jaz]
It’s good you’ve got the good stuff. I would say use it more, but when you next have some direct restorations, please, I really want you, cause you’ve got all the time in the world as a student, right? I want you to go through that difficult period of using rubber dam, quadrant, isolate the quadrant, watch my webinar. I’ve got 30 videos on Protrusive Guidance. It’s like five minutes, 15 minutes of cases I really struggled in, unedited raw footage of me putting on rubber dam. Revise all of those.

And I want you to use that technique. And I want you to promise me that you’re going to use rubber dam because now is the best time. You start practicing now. Wow. You’re going to absolutely sail.

[Emma]
Yeah, definitely. I think it’s so frustrating, but once it’s on, it’s good. And once you’re good at it, you’re good at it, you know.

[Jaz]
Buy a packet of flossettes, cause maybe you don’t have it in clinic so take your own flossettes with you, okay? You got the unodent rubber dam, which is great. And follow the instructions in those videos and the webinar. Trust me, like you’ll have such a less frustrating time.

[Emma]
Yeah. And hopefully I get to do some indirects.

[Jaz]
Even just direct. I want you for, you know, comps, for your comps as well. That’s where you practice.

[Emma]
Yeah, yeah, definitely. And they’re quite big on rubber dam in Glasgow, so it was good. My next question that I did want to ask you, Jaz, was about intraoral scanners. We have one in the dental hospital to let the students play with. I’m sure it’s on the staff clinics, probably.

[Jaz]
I can imagine all the things the students have been scanning.

[Emma]
Yeah, taking us like half an hour.

[Jaz]
And then lose the handle, it’s a funny thing.

[Emma]
Yeah. Do you think, like in your practice, like in your surgery, Is an intraoral scanner like an essential for you, or do you think it’s very much possible to achieve the same results with traditional impressions?

[Jaz]
Oh, I mean, impressions are king. Like, impressions are great. But the question really should be switched. Is it possible to achieve the results with digital that the good results we’ve always had with analog? And the answer, I think, is yes, in most cases, but you have to remember a few rules. When you’re using something like silicon based impression materials, because the flow of it, it can go under the sulcus, it can capture the details.

With a scanner, you can only capture where the light goes. And so with digital techniques and scanning, you need to be more aggressive with your retraction, with your retraction cord, with your suppression of the tissues. Tissue management becomes more complex when you go digital. Tissue management, it’s easier because the light bodied silicon will flow in those areas and will save you.

So analog is amazing, but digital with these quality scans, I mean, like prime scan, that kind of stuff. They’re really, really great. I use a scanner, which is not that as good for restorative. I use the iTero. I don’t care if I’m saying brands and stuff. It is what it is. They’re good for Invisalign and that kind of stuff.

But the one I use at the moment, It’s not wonderful for restorative. I’ve been using it fine. I just have to then take extra time and really suppress my tissues and try and spend what time get as the best scans I can. When it comes to sub gingival areas and especially vertical preparations, You know, I went on Marco’s course in Sicily and he showed me my own scan.

Like the, what the technician sees with his scans is sometimes it will make you cry. Impressions for subgingival areas and vertical preparations is still king and scanners are still catching up. But for things that are supra gingival, scanning accuracy and the ability to produce really good restorations with a good fit is fantastic now. So it depends on now if you’re working subgingivally or super gingivally. The answer is scanners are pretty much there, but they still have a bit more improving to do.

[Emma]
Yeah. Do you think impressions will ever, I don’t know, not not be a thing?

[Jaz]
I think eventually they’ll be phased out. I think so. I mean, the amount of impressions, I would love to speak to a technician and find out the amount of technicians that are getting in analog work. And what percentage of that work it is. I’m sure it’s declining rapidly at the moment. I’m sure there’s still niche scenarios where impressions are king and analog is king, but most indications, even dentures are going very digital, believe it or not. So digital is the way forward. There’s still the few, sometimes you use your analog to compliment your digital. So I don’t think it’ll be fully obsolete, but I think they might be five, 10%, whereas the digital will be the 90%.

[Emma]
Well, that’s good. Cause I’m rubbish at taking impressions.

[Jaz]
You’ll be rubbish at scanning as well. You think it’s easy. iTero scan, I took, like, took me like half an hour. Now it takes like three minutes, but it’s like a steep learning curve with everything.

[Emma]
Yeah, definitely. But, no, that’s interesting. That’s interesting. The last thing I did want to ask you was about the lab and I know that you’re very specific with your labs. You’ve got great communication with them. Like, are there specific challenges or preferences that you have when working with labs on ceramic restorations specifically?

[Jaz]
It’s a journey you go on with your technician and a great piece of advice that was given by my technician, Graham, who came to the podcast a few times is try and find a technician who’s like a similar age to you and you work together and you send all your cases to that guy or gal and then you communicate over WhatsApp and you grow together.

There’s something really beautiful about that. And then dentists, when I say to dentists that I helped to train my technicians to improve this element of it, they think, but you’re a dentist. What do you know about the technician side? How can you train them? But when you speak to a technician, they’re very grateful.

Equally, the technician trains me. And he tells me, he shows me my scans at all. You know, you should have smoothed this amalgam in the mesial, like you didn’t. And it’s made it more difficult for me and you’re constantly learning together. So firstly, the lesson here is communicate with the technician, even if you’re using a bigger lab and you don’t even know the name or the face of the technician that’s making it work, the more information you give them, the better.

So if you just say Emax crown, A3 upper left six, okay, how much care love and attention do you think the technician will give they’re just going to put the bottom of the pile and they’ll make you something that’s acceptable. Hopefully. If you say lithium disilicate, overlay restoration upper left six shade A three, but it’s got hints of a higher chroma cervically. My mesial margin was a bit questionable.

Please let me know if it was acceptable or not. Please give me some feedback. Okay, so you’re inviting them to give you feedback. There were shim stock holds on the upper left first premolar, second premolar. The second molar wasn’t holding shim, but the third molar was. So now I can verify the bite. Okay.

And then you say that please follow the cuspal inclines of the adjacent teeth because this patient’s got group function. And I’d like to keep that because we’re not changing anything about that basically. Try and aim for a couple of contacts with the opposing tooth, where you see the cusp of the opposing tooth, try and create these landing areas in this molar. And so when you give all that kind of information, All right, you’re going to get something much better back.

[Emma]
Yeah, yeah, and who I have on a Friday morning on my Pros clinic, Mr. Fogel. He was a dental technician before he was a dentist.

[Jaz]
They are the best dentists.

[Emma]
And he, yeah, he loves Pros. He loves it so much. And we were doing a tutorial about lab, some, I can’t remember what it was about, anyway.

[Jaz] I have no idea what it was about. It was something I just showed up hungover. It was-

[Emma]
He was talking about inviting your lab technicians to critique you and vice versa. And just about like-

[Jaz]
Some technicians are scared to critique their dentist because they’re thinking of losing business, losing a client. But when you give them from the get go, from the get go, I tell Graham, listen, don’t beat about the bush with me. If I’ve done something not to your standard, you gotta tell me. Equally, when you cock up, and he does, and I cock up sometimes, and you know, when he drops the ball, I’ll tell him.

I’ll send him, because I’m recording my videos of me doing the procedures, unfortunately, he gets the crudest feedback. He sees me struggling to fit the crown that he made, and he’ll see that, oh, yep, I kind of overdid it on that medial contact, and he gets to see video footage, or very rarely, but sometimes I reject a crown, because there’s an open margin there.

And you get to see my photos and videos. So it’s painful being a technician sometimes when you’ve got the clients like me, but equally when I’ve done something wrong, he’ll tell me, and it’s a beautiful to grow like that. And our mistakes are getting less and less. And we are able to really serve our patients better.

[Emma]
Yeah, definitely. And I think it goes both ways. Like, I think dentists, well students anyway, are often scared to speak to their lab or if something’s not gone quite right to talk to them about that. But Mr. Fogle was saying, he’s like, if you phone up a lab, he’s like, I’ve never spoke to some, a technician on the phone that wasn’t very pleasant. It’s like, no one wants to lose business at the end of the day and you want to have a technician. So yeah.

[Jaz]
I was always taught that a average dentist and a good technician will do very well. So pick your technician wisely. Pay a little bit more premium for your technician basically. Get a good technician and they will save your bacon.

[Emma]
A hundred percent. And I think that’s all the questions that I had to do, Jaz.

[Jaz]
Thank you so much. And I’m excited for you to, A, start doing some rubber dam dentistry. I would love for you to do it and feedback, see how it went. And yes, but first, a hundred times you’ll be frustrating, pulling your hair out.

And the hundredth first time you’re like, you know what? Today I isolated and I didn’t cry while isolating. It was good, right? So you know, you have to go for it, please. You have to go for it. And then also when you start coming to your first indirect restoration, let’s have a chat. Tell me what material you got in mind, what your technician suggested, what your tutor said.

And you’re in this funny position as a dental student where you kind of, you don’t have free mind. You’re kind of led by what your tutor says on the day. And then there might be a different tutor on the day of fit. And they think, what the hell was this initial thing in this life? And that’s how it works. Embrace it, enjoy it, embrace it. As long as you’re there, like a sponge learning, you will fly.

[Emma]
Yeah, for sure. Like, I’ve been frustrated a couple times with treatment plans changing, different clinicians like, pick their brains about it. They’ll all have different opinions and that can be frustrating at the moment and maybe for the patient as well, but it’s like a goldmine of tips and tricks to pick up on. Just pick everyone’s brains whilst you can.

[Jaz]
It’s important. So whenever someone changes a plan, that’s totally cool. But can you say, hey, Mrs. Smith, like, I see that you changed this from a filling to a crown. Or, use the other way around, crown to a filling. May I ask the rationale behind that so I can learn this a bit more?

And then just, yeah, listen and learn and you know that everything is justifiable. There’s no hard and fast rules and dentistry. You can just justify everything as long as there’s a good why and a good reasoning behind it.

[Emma] Yeah, for sure. And I can’t speak for any other universities, but I think dentists that are in education, like they’re all a bunch of nerds. Like they want to talk about it. They want to be asked why they love talking about it. So they will stand there and show your ear off for 20 minutes if you want them to.

[Jaz]
And you know what, sometimes they just want, like, sometimes it’s a wish that students were more receptive and not on their phone. And sometimes if you’re there to listen, they will give you something. If they suss out that you’re actually really keen. Like, they will give you everything. Like, if you show that enthusiasm and keenness, you will really gain a lot. So, keep that in mind, guys.

[Emma]
Definitely, definitely.

[Jaz]
Great, Emma. I hope you have a, okay, by the time this comes out, maybe after Christmas, but happy Christmas, happy new year, and I’m excited to grow together in 2025 and inspire students all over the world. This month’s notes were ceramics, right?

[Emma]
Yes, ceramics, yes. So those protocols that we’re talking about, air abrasion, acids, all those sorts of things, different materials, when, when not, you would maybe use them, all those sorts of things.

[Jaz]
Great, and do you remember how many pages it was?

[Emma]
I don’t actually, no.

[Jaz]
I saw it was very comprehensive, lots of pages basically, but like lots of good stuff, very visual, nice protocols. So remember students, email student@protrusive.co.uk to prove that you’re a student. We’ll add you to space and you can access the crush your exam section where all the notes are written by Emma.

Any images that we take, we always reference them, which is really important to say thank you to all the people because it’s difficult to generate these images sometimes, but we always reference where we got them from. And I think what we’re building here is a really fantastic resource. So, Emma, thanks so much. Keep up the good work and I’ll catch you soon.

[Emma]
Perfect. Thank you.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end, as always. Thank you to Emma and Team Protrusive. Without the team, I would be totally burnt out. The podcast would have died years ago, but it’s down to you guys, your comments, your love and hard work and dedication from the team that allows Protrusive to continue and thrive.

We’ve got so much planned for 2025. The most happening place to be right now is our Protrusive Guidance app, our community of the nicest and geekiest dentists in the world. That’s where you ask your questions that you feel embarrassed to ask anywhere else, and you don’t need the anonymous function.

There’s so much toxicity on Facebook groups, but not on Protrusive Guidance, because you, listening right now, watching right now, the fact that you made it this far, it means that you’re definitely very geeky. And you’re probably very nice. If you identify yourself as a Protruserati, I’ve realized that you guys are just amazing people.

And so come and join your tribe on Protrusive Guidance. That’s protrusive.app to join in. For those of you on a paid plan, you can get your CE certificates. Just answer the questions below within Protrusive Guidance, and Mari, our CPD queen, will sort you right out. Oh, and don’t forget to like and comment below.

What other topics would you like covered? Thanks again for watching to the end. I’ll catch you same time, same place next week. Bye for now.

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What influences your decision when choosing ceramics?

What are the main ceramics nowadays—and do porcelain-fused-to-metal still have a place in dentistry?

Are the protocols different for various types of ceramics and crown materials?

How important is rubber dam isolation, and is a split dam good enough?

In this Back to Basics Protrusive episode, Jaz teams up again with Emma Hutchison, ‘the Protrusive Student’, to break down these critical questions and simplify the world of ceramics. From decision-making frameworks to practical rubber dam tips, this episode is packed with insights to elevate your practice.

Whether you’re a student navigating the foundations or a seasoned clinician revisiting the essentials, this discussion offers a fresh, evidence-based perspective on mastering ceramics in dentistry.

Watch PS013 on Youtube

Key Takeaways:

  • Understanding the role of metal ceramic crowns is crucial in modern dentistry.
  • Monolithic ceramics are preferred for posterior restorations due to their strength.
  • Layered ceramics can enhance aesthetics but may compromise strength.
  • Proper crown preparation is essential for successful restorations.
  • Communication with lab technicians is vital for successful bonding.
  • The choice of ceramic material largely depends on the amount of enamel available.
  • Following manufacturer protocols is key to achieving optimal results.
  • Bruxism patients require careful consideration in material selection.
  • Rubber dam isolation is crucial for predictable bonding.
  • Digital scanning requires more aggressive tissue management.
  • Impressions are still valuable, but digital methods are advancing.

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

Highlights for this episode:

  • 03:52 Emma’s Exam Experience
  • 07:28 Feedback on Previous Episode
  • 08:00 Discussion on Ceramics in Dentistry
  • 10:51 Practical Applications and Material Choices
  • 19:45 Monolithic vs. Layered Ceramics
  • 24:18 Exploring Milled Cobalt Chromes and Gold Crowns
  • 26:14 Challenges in Fitting Restorations and Bonding Techniques
  • 30:03 Rubber Dam Techniques and Benefits
  • 37:01 Intraoral Scanners vs. Traditional Impressions
  • 40:14 Effective Communication with Lab Technicians
  • 44:25 Conclusion and Future Plans

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 010 BASIC SCIENCE (Dental materials)

Dentists will be able to –

  1. Identify the suitability of ceramics based on their strength, aesthetics, and application.
  2. Highlight the importance of proper crown preparation and manufacturer protocols for optimal results.
  3. Emphasize the importance of rubber dam isolation and compare the benefits and challenges of analog impressions versus digital scanning.

If you love this episode, make sure to watch Composite vs Ceramic with Dr Chris Orr – PDP030 and make sure to read the Protrusive Notes!

Click below for full episode transcript:

Teaser: I do not place lithium disilicate and I cement it. So for me, the way my mind works is if I'm cementing and not bonding, if I'm cementing just using a GIC based cement, so I'm not relying on enamel for adhesion, why would I use lithium disilicate? Using lithium disilicate posteriorly and bonding it, excellent strength, good, it's going to be fine, as long as you give it enough thickness, 1.5-2mm, you're golden, okay.

Teaser:
If you don’t respect the thickness, or if you use cement and you don’t bond it, you’re going to really compromise on the strength, you’re not going to get the high strength. So therefore, the same material, lithium disilicate, cemented is a completely different ceramic to the same ceramic lithium disilicate, bonded.

You need to know your material and the correct protocol for your material. You’re not supposed to air abrade lithium disilicate. But I know some clinicians who whatever material they get back from the lab they will air abrade it. You do introduce micro cracks. Whether it or not it’s clinically significant or not, I don’t know, but I’m one of those people that I follow the rulebook for any material I use, any bond I use, like exactly how the manufacturer wanted it, I pretty much will follow that.

The other thing to bear in mind is, how important is it to you that this molar tooth, looks absolutely gorgeous. How important is it to you? And I wait for them to say the answer. Okay, and I say, okay, you want it to look gorgeous, but what if I told you that if you accept that it’s going to look good, but not gorgeous, it will last way longer because the chance of it breaking is way less. What’s more important to you? Longevity or beauty?

Jaz’s Introduction:
When I was a student, like many things, ceramics were very confusing. And fast forward many years, when I qualified, they were still very confusing. What I present today in this back to basics series with Emma Hutchison, the Protrusive Student, is a simplified overview of ceramics and how I view them.

My views are based on the courses that I’ve been on, the evidence that I’ve read, and my daily clinical practice, which makes up a third of evidence based dentistry itself. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Hey, the last one on extractions. I mean, you guys loved it.

So thank you so much for everyone who liked it and commented. It really helps us to keep going. I was always unsure about this Protrusive Student series and going back to basics, but you guys are loving it. And I really appreciate that. I mean, Emma will continue to make dentistry tangible for students, but a lot of these episodes are very useful for dentists, like a back to basics, revisiting the foundations.

There’s something very validating about that. Sometimes you can only measure your growth when you look back and listen to an episode like this and feel that, you know what? I knew kind of everything and look how much I have grown. There’s a real beauty in that. So in this episode, we cover decision making in ceramics.

What influences your decision. What are the main ceramics that I’m using nowadays and do I still use porcelain fused to metal? Are the protocols different for the different types of ceramics and crown materials? How important is rubber dam isolation? Is split dam good enough? And we’ve even thrown in some rubber dam tips in there for you.

This episode, like the last one, is eligible for CE. Protrusive education is a PACE approved provider. And we also satisfy the criteria for the GDC. All you have to do to play and collect CPD is answer the five questions and get 80%. That’s only available on www. protrusive. app. Once you make an account, you can download it on Android and iOS, listen on the go, answer the questions, also answer the questions of the past episodes that you’ve listened to, and validate your learning.

An opportunity to reflect, which forms part of your personal development plan. We’ve also got the notes from this episode written by Emma, all about dental ceramics, like a cheat sheet for any student. It does go quite deep, but it’s all the stuff that you need for your exams. And that’s in the crush your exam section of Protrusive Guidance.

Once you join Protrusive Guidance, you just have to email student@protrusive.co.Uk so we can verify you’re a student and add you on there. Now let’s join the main episode and I’ll catch you in the outro.

Main Episode:
Emma Hutchison, the Protrusive Student, welcome back. You’ve just had an exam. How did it go?

[Emma]
It was okay. It was a structured clinical reasoning exam. And which was something that, it’s something that Glasgow only introduced. I think two years ago, it might’ve been last year, actually. So no one really knows what was going on. So.

[Jaz]
An example question from there that was a tough one.

[Emma]
Yeah, so you’re basically given a few cases, and you have like an assimilation time to sit in a room and look over these cases. You just get radiographs, clinical photographs, a bit about medical, social history. So you have 25 minutes per case to read over. You don’t know what questions you’re going to be asked, and then you go in, and you’ve got, for each station you’ve got two tutors or clinicians, and you sit in front of them, very closely actually, I thought they were going to be a bit further away across the room, but you were sitting right in front of them, and they just kind of grill you on your treatment plan.

If it’s oral medicine, they’ll ask you questions about histology, things about medications as well. Like, we had a patient that was on Warfarin, so they’re going to ask about all the INR, things like that.

[Jaz]
You knew that. You knew all that, right?

[Emma]
Yeah, yeah. It’s just hard because you have no idea what’s going to come up. So, a lot of it is reading over your guidelines, SDCEP, American Endodontics, things like that. So, it’s very intense. It’s very intense, but I’m glad it’s over.

[Jaz]
Which was the question that stumped you?

[Emma]
So, you get your topics two weeks in advance, so we were restorative and orthodontics as well. And for restorative, I thought I was going to completely fumble because it is such a huge topic with ortho at my level.

In dental school, there’s only so much that they can ask you, I suppose. But the ortho one was really, really tricky. They wanted very specific answers. It was kind of good cop, bad cop. It was very intense.

[Jaz]
It was all surrounding that specific case that they gave you, right?

[Emma]
Yeah, yeah, so we had a case of a little boy who was like class three. You had to go over all the treatment plans which, in theory I do know, but it was quite intense. But everyone in my year sort of felt the same, so we’ll see how it goes.

[Jaz]
With dental exams I couldn’t read it when I came out like, when I did maths, back in the day, in A level maths, right, I was pretty good at maths, when I wanted to be.

Like, I went into my C4 last exam knowing that all I needed was 13% to get my A. That was the highest grade at the time, they’ve got like A star or whatever now in A levels, but I needed 13%, right? So, I completely didn’t study C4 at all. I just knew that I can just get a 13% like by writing my name.

So I’ve got like 55 in that. And everything else I’ve got like 99 and 100s, basically. So I was, when I was wanting to be, I knew I could switch it on for maths. And then, so when I come out of maths exam, I knew, okay, I’ve aced it or I flunked it. I knew, right. When it came to dental school, I was like, I had no idea, especially with those kind, when you’re being interviewed and OSCE’d. And sometimes I come out and think, Oh my God, I flunked this. And then I surprise myself. Like, it’s difficult to read.

[Emma]
Yeah, it’s really difficult to read. And they said we had a sort of recap of it and they were saying, you know, we did purposefully examine it a bit harder because when it comes to our case pres, and we’ve got another clinical reasoning exam later on in the year. I don’t know, they wanted to give us a bit of a fright, I suppose. They said in hopes that the real thing, the big, big exams that are a lot more heavily weighted, will be a bit nicer.

[Jaz]
It’s a good approach. They give you a real tough time so that the actual thing will be easier and nicer, so that’s good. Well, today’s topic is ceramics. Our last episode, Extractions, went down really well. Everyone loved it, so well done Emma. It was great questions that you’d asked. Everyone loved the avocado analogy, but more importantly, did you resonate that analogy? Have you done an extraction since? Maybe you haven’t, I don’t know. You tell me.

[Emma]
You know, I actually haven’t done an extraction since I was on a good roll with extractions and now it’s completely stopped. So hopefully in the new year.

[Jaz]
But right now, you know what an application point feels like now you know to liken it like an avocado and stuff and then the removal of a nut. So that was good. I enjoyed that very much. And today’s ceramics, right? So ceramics was a topic that again, I mean, so many topics at dental school confuse you, mostly do. But this is in materials. Like I was okay at memorizing about leucite reinforced and then the history of ceramics and stuff.

But at the actual practical element of delivering ceramics and actually, what do you actually do in the real world? I had no idea. Like really, it was very heavily, heavily emphasis on PFMs. Like your exam was a PFM, porcelain infused to metal or metal MCC metal ceramic crown, as some people call it. And so, I’ve hardly done many since qualifying of those crowns.

Yeah, I still do. And we’ll talk about the indication for that. But nowadays in a world of all ceramic, what I was being taught was already quite outdated. So I’d be interested to know. What kind of crown preparations are you being taught? What kind of materials are you being taught to use on your patients?

[Emma]
Yeah, so I think in Glasgow, we’re still learning about metal ceramic crowns, how to prep them, but we are also learning about all ceramic alternatives, I suppose. So my first question was going to be about, do metal ceramic crowns still have a role in dentistry today? Like, especially in private dentistry, I wonder. Or have they largely been replaced by all ceramic?

[Jaz]
The answer is they’ve largely been replaced, but they still have a role. To get PFMs, like, working well, right, and looking good, you need space. You need that 1. 5 to even 1. 7 millimetre, if you’re making it look really aesthetic, right? So you have the metal layer, the opaque to block the metal layer.

Then the ceramic and to actually give it a good bulk to make it look pretty. It needs a lot of space. And so that ends up being a very invasive preparation. We’re trying to move away from that. So to do a proper PFM that looks good, it still has a place, but maybe not so much. And so the time that I would use it and a lot of today is very much, if you had a different podcast host, you’d be getting different answers.

So a lot of it is based on my opinions and experiences, and everyone’s, I think, everyone’s got a story, everyone’s got experiences that have shaped them, that shape their thinking. So for me, the time I use PFM nowadays is, if I’ve got a severe, high force, bruxist patient, and I would like to have a metal occlusal.

Because it’s got very good wear properties. It’s got very good strength and longevity. I can be more conservative by having metal only, right? So I don’t have to drill as much. But then maybe on the facial, I’m not going to go for a super aesthetic. Maybe it’s a first molar, maybe it’s a second premolar.

And so I’m still going to be a minimal prep and accept that it’s going to be an ugly looking PFM. Like, only the buccal will have porcelain, but it’ll be a very thin porcelain, and it won’t be very aesthetic, but for this more functional tooth wear case, it’s going to be completely adequate. So that’s where I’m using it at the moment, whereas we’ve pretty much moved to zirconia and lithium disilicate, which are the two main types of ceramics.

[Emma]
Yeah, yeah. So another question that I did have was, what factors determine your choice of ceramic material for I’m going to say largely for posterior versus anterior restorations.

[Jaz]
Okay. It’s very simple and it doesn’t change so much depending on anterior versus posterior for me.

[Emma]
Okay.

[Jaz]
Okay. So put it this way. If I know that I need to go indirect. So I’ve decided, and so again, recap a little bit. For posterior, you know that it’s too ambitious to go direct here. You’re literally having to do an MODBL. You’re going to find it difficult to get good contact points. Maybe the tooth is root filled and you need to cover over the cusps so that the cusps don’t bend and flex and break.

So there’s so many good reasons sometimes to go indirect. So, when we made that decision that we’re going indirect posteriorly, if I’ve got enamel, all the way around, I’ve got a decent amount of enamel and the tooth isn’t so destroyed. It’s still got some enamel to bond to. My substrate to bond to is good. I will go for a bondable partial coverage restoration. So do you know what I mean by partial coverage?

[Emma]
Like an inlay or an onlay?

[Jaz]
Yeah. Not so much inlay in this scenario. I’m talking about an inlay is basically you could have done the DO composite, but you asked the lab to do it instead of you. That’s essentially an inlay. Right? The onlay more like covering over the, like an overlay.

You’re covering over the cusps. And you’re bonding to the enamel. The ceramic, etchable ceramic, which you talk about, okay, lithium disilicate, right? I will go lithium disilicate because it’s conservative. Why should I have to remove any tooth structure that I don’t have to? If I can bond to the ceramic, it has no retention form.

It’s got a tiny, teeny bit of resistance form. We’ll talk about that. But I’m relying on the quality of the enamel for my bonding. It’s very conservative. You literally, all you have to do is remove the old MOD amalgam. Take the cusps down a couple of millimetres and that’s your prep pretty much done.

You just smooth it and you block out the undercuts with composite. So the prep is enjoyable. You feel like you’re saving so much tooth structure. And if I’ve got enamel, I will use lithium disilicate. Why lithium disilicate? Because it’s got very predictable bond. I will not use zirconia partial coverage restorations, even though nowadays some clinicians are.

And I’ve asked this to real top dogs, okay? I’ve asked this to Dr. Nasser Baghi in 2018, is a top dog in the US on zirconias and ceramics. Recently, where was I? I asked Chris Orr this question at BACD just this year, 2024. And I said, when these zirconia restorations are showing such promising data that we can bond to them, should we be moving away from lithium disilicate?

He’s like, no, we have this beautiful material, lithium disilicate, that’s predictable and it’s got so many advantages. Let’s just stick to this. I mean, he’s not yet moving on to zirconia posteriorly. If posterior and has good enamel, I’m going Emax, which Emax is a brand by the way, it’s a brand of lithium disilicates by Ivoclar.

Okay. The other one is LiSi by GC. So they are both examples of lithium disilicate. Now that same molar that has got less enamel, maybe the mesial and distal caries is really deep and you’re on dentine now. And you have just generally less tooth structure. I’m instead going to go to for zirconia, I’m going to go a full crown all the way around 360 degrees and I will prepare and this might blow your mind as a student, but something called a vertical preparation. Now being the Protrusive Student you have access to all my webinars.

You have access to everything. You should eventually do VertiPrep for Plonkers. It’s something that teaches everyone to do their first vertical crown, but essentially there is no shoulder. There is no chamfer. You’ve hardly drilled into the tooth. It is a super conservative way to deliver a crown in a really lovely conservative way.

So I’m getting all the benefits of having retention and resistance, but I’m not sacrificing much more tooth structure to get that. So if posterior is either lithium disilicate, if I have enamel, or zirconia, if I don’t have enamel. And then, like I said, in that severe bruxist patient, if I want metal occlusal, I might go PFM, but that’s rare. Any questions on that before I move to anterior?

[Emma]
No, it’s a different take to what we’ve been taught at uni, but it’s interesting, like, it makes sense.

[Jaz]
What have you been taught at uni? I’d love to know.

[Emma]
So a lot of the things we talk about at uni are purely based on like strength and aesthetics and how certain ceramics are better anteriorly because they’ve got good aesthetics but then posteriorly you want to use something else because they’re stronger, they’re more robust.

[Jaz]
Can you give examples? Do you remember the names of ceramics? Can you give some examples?

[Emma]
Is it lithium disilicate?

[Jaz]
Don’t worry if you don’t remember. It’s okay. I hardly knew anything about ceramics when I was at your age. It’s great already.

[Emma]
Is it lithium disilicate that’s better for like translucency in the interior or have I got that the wrong way around?

[Jaz]
No, no, it’s got the different ingot types basically. So it’s like high translucent, low translucent. So yes, lithium disilicates can be quite nice looking. A lot of veneers are done in this type of material, but it is totally appropriate to use posteriorly as well. Let me say again, it is totally appropriate. And here’s the magic bit.

Now, the most, probably the most important part of this podcast will be this, providing you have enamel because if you have enamel, you can bond. What I don’t do is I do not place lithium disilicate and I don’t cement it. So for me, the way my mind works is if I’m cementing and not bonding, if I’m cementing, just using a GIC based cement, so I’m not relying on enamel for adhesion, why would I use lithium disilicate?

Do you know why? Do you know why I’m against using lithium disilicate? The magic property of lithium disilicate and feldspathic porcelain veneers, the magic of what happens when we bond them.

[Emma]
No.

[Jaz]
And that’s totally fine. I wouldn’t have known at your stage, but the main lesson here is feldspathic is a type of ceramic, basically. It’s a very beautiful ceramic traditionally used for veneers. Not so much anymore because the number of technicians who are skilled at this is less and less and less as we’re getting more CAD cam and whatnot, and then labs are getting more digital, but essentially these veneers are beautiful. But they are weak.

Something from my mind, I remember like 90 megapascals, let’s say, right? So they are weak compared to 250, 300 megapascals of lithium disilicate. So they’re weak, but they’re beautiful. But once you bond them to enamel, they are so strong. It’s a bit like a tile, a glass tile. If you drop the tile, it’s going to break.

If you actually glue that tile on the floor, it is strong. That was the analogy that was given to me when I was a student. I still remember this basically. So using lithium disilicate posteriorly and bonding it excellent strength. Good. It’s going to be fine. As long as you give it enough thickness, 1. 5, two millimeters, you’re golden.

Okay. If you don’t respect the thickness. Or, if you use cement and you don’t bond it, you’re going to really compromise on the strength, you’re not going to get the high strength. So therefore, the same material, lithium disilicate, cemented, is a completely different ceramic to the same ceramic lithium disilicate, bonded.

[Emma]
Yeah, okay. I didn’t know that. I’d never, like, it probably has come up in lectures before, but it’s not something that I’ve ever really thought of.

[Jaz]
So that’s why I don’t do lithium disilicate cement, because I’ve got this wonderful material, super strong, called zirconia, and that is really amenable to cementing, and I can get my retention resistance form, because I’ve decided I don’t have much enamel here. So I’ll do a vertical preparation crown posteriorly using zirconia, which I’m going to cement. You could be fancy and bond it, but why complicate the protocol?

[Emma]
Yeah, that’s true. No, that makes sense actually. Think about it. I’ve never heard the analogy with the tiles as well and how it’s a totally different thing once it’s actually glued onto the wall or the floor.

[Jaz]
They behave differently. But I mean, the other key lesson here is giving enough occlusal clearance. So the biggest mistake we make when giving occlusal clearance is A, we don’t give enough. And we think we’ve given enough, and he gets a lab, and they’re kind of literally squashing and squeezing this material in, okay?

And, I don’t know why dentists are so afraid, myself included, back in the day, trying to be as conservative as possible, occlusally. Yes, it’s good to be conservative, but with a lot of these broken down teeth, the occlusal part is like composite. The tooth is lower down, right? So, I’m happy to sacrifice more tooth structure, have a more thickness of crown material that will really make it unbreakable.

So, just remember that. And the common place that we will under reduce is the fissure. The actual fissure itself, okay, is the most likely area that will be under reduced. And the other common mistake is, let’s say you’re doing a pre molar crown, right? And what you do is you end up flattening the occlusal.

You don’t follow the same anatomy, right? You see like the cuspal anatomy, basically it goes rise and fall and rise. If you don’t respect that and you flatten it, great. The cusps have been reduced nicely, but that middle portion, you’ve hardly reduced it. And that’s a big technicians. That’s the biggest issue they have.

So remember when you’re doing the occlusal reduction, follow the anatomical form of the tooth. So it’s a uniform reduction, and then you’re going to get enough thickness where it matters. ‘Cause that’s where the fossa of the tooth is, that’s where the opposing cusp will put the occlusal load down.

So if you want ceramics, that’s not going to fracture. You’ve gotta do that. The other thing, which we haven’t talked about, which you’re probably going to ask about anyway, but do you know the difference between something called like, what I mean when I say the term monolithic, and when I say layered, do you know the meaning of this?

[Emma]
Is this the way that it’s like milled or put together or constructed?

[Jaz]
Not quite, like once you have that lithium disilicate, right, that block is ready to go on, right, there’s two ways to treat it. One is you accept it how it is. And it’s a really strong material. But it’s not as beautiful as it could be.

We can make this. So let’s talk about an anterior crown, right? So if we’re going to do a lithium disilicate upper right central crown, central incisor crown in lithium disilicate, if you have a monolithic, which means that it’s just the pure lithium disilicate material, that kind of like a one shade.

It’s got some transparency, but it is like the one bulk basically. Versus the same crown. But what you do now is you shave the buccal of the crown down a bit by 0. 5 millimeters, for example. And then you add some beautiful weaker ceramic on layer it. You put these effects in.

Okay. That second one, that layered porcelain fuse on top of it, basically. It’s going to look so much more beautiful. We’re going to put those effects in. It’s going to look gorgeous. But it’s now weaker because now you have an interface between the monolithic ceramic and the layered ceramic. And therefore another golden rule here is why would you do a layered ceramic posteriorly?

Why? Don’t do it. The reason why zirconia had a bad rap initially, and also Emax, lithium disilicate had a bad rap initially. It’s because dentists were doing these gorgeous restorations posteriorly and they were layered. So they were actually putting this beautiful weaker ceramic in the occlusal loading area and guess what was chipping? It was delaminating, it was chipping away. A bit like, maybe you’ve seen this Emma, have you seen PFMs where the porcelain’s broken away and the metal’s left behind?

[Emma]
I’ve never seen it, no, but yeah it can happen.

[Jaz]
Not even as your role as a nurse? Do you remember not seeing it as a nurse maybe?

[Emma]
Not that I can remember, no, not that I can remember.

[Jaz]
Fine, so it’s the same thing, like, ceramic is bonded to the metal. In the same way the beautiful ceramic is bonded to the monolithic stronger form, basically. So anteriorly for some patients who are high force, maybe they’re bruxist, you can still do a monolithic Emax or monolithic lithium disilicate. It’ll still look good.

Maybe a 7 out 10 before an aim for a 9 out of 10 plus. You want that same ceramic, but you want it layered, basically. And so that’s the difference. So anteriors tend to layer. For most patients posterior, monolithic. Even when it comes to zirconia, you know? Yes. The downside is they look very opaque.

They look a bit too white, right? But it really depends. It’s a conversation I have my patients. How important is it to you that this molar tooth right looks absolutely gorgeous? How important is to you? And I wait for them to say the answer. And I say, okay, you want to look gorgeous, but what if I told you, if you accept that it’s going to look good but not gorgeous, it will last way longer because the chance of it breaking is way less. What’s more important to you longevity or beauty? And you can’t have both sometimes. And let the patient decide. Because that is then the ultimate level of consent.

[Emma]
Yeah, and would that still be your same protocol for patients that are heavy bruxists?

[Jaz]
Okay, so heavy bruxists. So let’s say that I’m treating heavy bruxists basically, some schools of thought say that because you’re treating heavy bruxists like your molars which take the highest force because remember the masseter muscle is right there, right?

The medial pterygoid muscle is right there. It’s right by the joint. So the forces felt in the molar region are significantly higher than the forces felt on the anterior region. So then people say oh do gold on the second molars, right do gold restorations. They’re longer lasting the more forgiving or maybe do a milled cobalt chrome something metal is considerable. And I get that but the studies would say that as long as you give your ceramic enough thickness, it will fare well, even in bruxist.

And another thing with bruxist is that if it’s a true pathological bruxist, then you, they spend all that money, you want to protect it with an appliance. Things will just last longer. It’s something that we need to accept that. Okay, some patients will need protecting. But when it comes, even without protection, you give enough thickness, the ceramics will survive. But again, posteriors, I will go monolithic. I will not layer. As I say, no need to layer, especially on a bruxist.

[Emma]
Yeah. Yeah.

[Jaz]
You’re just asking for trouble. You’re asking for things flaking and breaking away.

[Emma]
No, that makes sense. And that’s largely what we’ve been taught at Glasgow as well. We’ve went over gold crowns and things like that, but not in too much depth really. But no, that definitely makes sense.

[Jaz]
The last time I did a gold crown on a second molar, guess how much the lab bill was?

[Emma]
Cool. I don’t know.

[Jaz]
It was like 400 pounds. Absolutely crazy. Like the price of gold is so high. And so I went to a British Society of Restorative Dentistry lecture once and there’s a chap, I think his name was Phil Taylor. I think I might be getting it wrong here. And he was a restorative consultant and he suggested that long time ago, he moved away from gold because of the cost reasons to a very good alternative, which is a milled cobalt chrome. And chrome is very kind to enamel. It is stronger and more rigid than gold, which actually is a negative property.

The strength of gold that is because it’s softer, it adapts nicely to the opposing dentition. Whereas the cobalt chrome is you have to get the occlusion a bit more spot on. It’s a bit less forgiving, but it is a very good long lasting, and you can still be very minimal in your prep basically. So I have been doing a lot of milled cobalt chromes when I want to do metal in the posterior.

[Emma]
Yeah, I’ve never heard of that. The milled cobalt chromes before actually. But is there a lot of labs that still do like gold crowns? Like they’re definitely still out there, but.

[Jaz]
Yeah, oh, they’re definitely out there. But be prepared for a, be prepared to prep as minimally as possible. Otherwise the lab bill will be crazy. So add more core, make sure you max out on the core and then prep back to do the bare minimum basically. But jokes aside, the labs will do it. Still fantastic restoration, right? And a lot of dentists will, when in a dentist in their 50s and 60s, when they need a crown, that busted molar, they will ask for gold.

They will ask for a three quarter gold crown or whatever. It’s a beautiful material. And what really inspired me to get into tooth wear was looking in someone’s mouth once. And I was a fine year dental student and just seeing this beautiful posterior gold work. And that really inspired me to go more to restorative.

[Emma]
My next question was about challenges when we’re fitting these types of restorations. So what are like the most common challenges and how do you overcome them? Because I know in practice, I’ve never done direct restorations myself yet. Hopefully soon. Indirect, sorry. Am I getting that right?

[Jaz]
Yes, so things that are made outside the mouth are put on.

[Emma]
Yeah, yeah, so I’ve not done any indirect restorations yet, but I know in practice like I’ve seen etching with acid and air abrasion, like are these necessary steps or are these steps that only some people will take in order to help prevent challenges?

[Jaz]
Okay, excellent question, okay, and you need to know your material. You need to know your material and the correct protocol for your material. You’re not supposed to air abrade lithium disilicate, but I know some clinicians who wherever material they get back from the lab they will air abrade it. You do introduce micro cracks. Whether it or not is clinically significant or not, I don’t know, but I’m one of those people that I follow the rulebook for any material I use, any bond I use, like exactly how the manufacturer wanted it, I pretty much will follow that.

The other thing to bear in mind is you need to have the right tools in your clinic to be able to follow those rules. So for example, if you are going to do a resin bonded bridge, or maybe even a zirconia resin bonded bridge, okay, and these for something like lateral incisors, in the right case, they last so well.

The Matthias Kern data is brilliant, but you need to follow the APC protocol, which means you do air particle abrasion. Use a zirconia primer. So if you don’t have a zirconia primer, don’t even bother doing this. Okay. And you use a composite resin cement, basically. And so you need to follow to get the success that you see in the papers.

You need to follow the protocol exactly. So the most common mistake I see is lithium disilicate restorations. The dentist doesn’t know if the lab has etched it with hydrofluoric acid or not. They don’t know. And then they are either just thinking, Oh, the lab did it and I’m not going to do it.

So maybe it’s never been etched. And the whole way that the lithium disilicate bonds to the enamel is because you want this like tiny little porosities in there to kind of like etched enamel, right? You want the ceramic to actually give you that bond strength. So you need to work with your ceramic properly.

So speak to your lab technician, find out who’s taking care of the etching. Once you’ve done the etching, you want to make sure you’re not air abrading something like lithium disilicate, and then you’re following your bonding protocol to a T. When I’m doing my vertical zirconia because I’m not bonding. We call it plonking.

We’re plonking this on. It’s so easy. Cut on a roll. Dry the tooth a bit, but I use something called IO clean to clean out the ceramic, but that’s not so important. So I’ve got my nice clean zirconia. I’m justly putting some cement inside. I’m plonking it on my thumb. It is so easy as long as there’s no bleeding and I think it is so, so easy when I’m doing a lithium disilicate, I’ve got rubber dam on.

No compromise. Rubber dam has to be on, okay? You’ve got to make sure that you can access the margins beautifully. I got PTFE tape on the adjacent teeth, make sure I don’t get any etch on the adjacent teeth. I’m following everything. You’re preparing the ceramic in a certain way, including the silane. You’re preparing the tooth in a certain way.

You’re air abrading. You’re making sure the air abrasion doesn’t touch the adjacent teeth, otherwise they’re going to stain in the future, all these things. So bonding is more technique sensitive. More can go wrong, but if you follow the steps properly, it’s incredibly predictable and it’s a very fun appointment.

I love both. I love both plonking my zirconia crowns. And also love spending a bit more time. So zirconia crown is half an hour for a lithium disilicate. Overlay restoration is 45 minutes to account for the extra steps, treating the ceramic, the rubber dam isolation. And so the main answer here is know your material, know the best way to treat it. Make sure you’ve had a conversation with the lab to know how they are treating it. And therefore there’s no confusion and you can follow the right protocol.

[Emma]
Yeah, definitely.

[Jaz]
Is there anything about a specific protocol that you want to know, or?

[Emma]
One question I did have actually, see when you’re saying you’ve got rubber dam on in that scenario, what teeth are you, like, is this like a split dam? I’ve just never seen this before in practice when someone’s got rubber dam on when they’re cementing a crown or bonding a crown, whatever. I’ve never seen that before. Like, are you doing a split dam? What teeth are you bringing through, like?

[Jaz]
Okay. Good question. Okay. So some colleagues would say that split dam is absolutely fine because then what you’re kind of reducing is you’re reducing that mouth breathing element of the patient. So split dam’s good, but I don’t see the point of split dam for most cases, because the gingiva is still there poking out. And if you’ve got like most of the times when I’m replacing these MOD amalgams, I’m doing these ceramic overlays. You’re literally equigingival or very slightly subgingival.

And so if you’re using a split dam, your papillae are just contacting your margins or there’s a fluid, a gingival crevicular fluid or sometimes blood. So I’m not a fan personally of split dam when it comes to bonding of my overlays. And what I will do is I’ll do a quadrant isolation. So if I’m doing a first molar, I will do a quadrant.

So maybe something like an upper lateral all the way to the second molar. I’ll make sure I’ve rehearsed the restoration when the rubber dam is on to make sure I’ve got a nice path of insertion, I can seat it, I can locate it well. I’m then following all the steps for getting the onlay ready, the overlay ready.

I’m following all the steps to get the tooth clean and ready. And then, while the rubber dam is on, and what the rubber dam does, it suppresses your papillae. Now, you can see clearly, you can walk a probe around your margins, okay? And it also makes it clean up easier as well, basically. Because then you’re not, as soon as you start cleaning up, you poke the gum, it’s going to start bleeding.

The rubber dam will protect you. It’ll give you some protection basically. So I’m not a big fan of split dam when it comes to bonding my ceramics. Remember Emma, you’ve got access to all of this and those dentists who are listening, watching, I’ve got example videos of through, POV, point of view.

I’ve got my loop camera on. I’m bonding these lithium disilicates exactly how Emma’s described on the rubber dam. So I’ve got all those videos in the Premium Clinical Video Section of Protrusive Guidance, so do check those out guys.

[Emma]
I think a lot of students can get quite frustrated with rubber dam and I think it’s because we’ve not yet seen the benefit that it can have, you know, we’ve not been doing this long enough to see the failures when you don’t use it.

[Jaz]
Oh Emma, when I was in third year, I remember being in a locker room and there was a dentist, I’ll name him Michael Spencer, with me and him I just, I remember him being there in the locker room and I said to him, when I’m at dental school, I’m never going to use rubber dam. I said, cut and roll all the way.

I said that to him. And now like, although I’ve relaxed in the last couple, I was like very much rubber dam police before I’ve relaxed a bit because I’ve now found like greater curve matrix, which gives such a wonderful seal that I need it less and less. So as long as the patient’s not a mouth breather and it’s the upper tooth.

I can pretty much do a lot of it using a nice metal shield, basically, as long as a mouth breather. If I’m working on the lower arch, I’m pretty much always using rubber dam. That’s my recipe at the moment. And for me, Emma, it’s like, forget the increased bond strength. Forget the risk of contamination.

Forget the access to the margins and suppressing the papillae. The main benefit of rubber dam for me is relaxation. That rubber dam is on, the patient can’t speak. Amazing. Fantastic. Rubber dam is on. Okay. And I can turn away and know that I can sleep well at night knowing that no one licked anything.

I can drop my onlay and it’s fine. It’s because the rubber dam is going to catch it. Comfort for the patient I think is good. I just find it’s a happy place to be. Rubber dam is on. It’s just a beautiful, happy zen zone, that’s my number one benefit. It’s very selfish. I use rubber dam because it reduces my stress.

[Emma]
No, the few times that I’ve placed rubber dam as well, like it’s very, very frustrating. Like I’m not good at it, but once you saw it.

[Jaz]
You’re not good at it because you haven’t done it enough. And you’re probably using the crappiest dam in the world, the green one. Right?

[Emma]
I think for, we actually do have the thick blue ones in the dental hospital, or they give us that for OSCE’s anyway.

[Jaz]
Well, okay. Again, so posterior, and again, everyone’s different with what they recommend. And for me, posteriors, I like to go medium thickness. Anteriors I go heavy. Because anteriors often you want to suppress the papilla a lot because you’re doing like bonding and stuff, that kind of stuff. Whereas posterior is you want it easy to go on. Right? So medium is a thinner. So, when I was learning, I was using that horrible green dam, right?

[Emma]
Yeah. I know the one you’re talking about.

[Jaz]
And the other terrible ones, that purple one, that ribbed purple one, they call that the devil’s condom. You punch one hole. You punch one rubber dam hole in it and you put it over your head. I think someone called a John Cowie, the Endo Chap in Bristol, mentioned from Instagram, it’s hilarious. You put one hole in it and you can literally poke your head through one hole and it’s just a nasty rubber dam.

Okay. And so really you want to go something like nictone. I love the unodent stuff, just some thin stuff that doesn’t tear. It greatly, you know, the right tools, the right job. It greatly improves your stress. It reduces your frustration when rubber dam becomes easier. Once you’ve got a system of doing it.

For example, I find that dentists, when they’re struggling rubber dam, they’re trying to do too much themselves. When I’m doing rubber dam, it’s a four handed job. Once I’ve got it over my clamp, I’m just setting in place. My nurse Zoe, she knows she’s going to get a floss set out. Floss set, not floss because guess what?

All of my nurses have got fat fingers and they struggle to floss my patient’s teeth. So you give them a floss set. And they can easily just go through and take that rubber dam with it, basically. Okay? I joke about the fat fingers. They struggle, right? There’s four hands in there. It’s difficult to get a floss set in. You remove the hand out of the equation.

[Emma]
Yeah. And I’ve never seen anyone do that. Like, I struggle so much. You feel so silly as the nurse as well. Like trying to floss that through. You’re like, I know how to floss, but it’s, it’s really, really difficult.

[Jaz]
Angulation and everything’s different. But when you use it, it’s so much easier.

[Emma]
Yeah. Yeah. And we use the, it’s the unodent one that we have at uni as well. I think we used to have the purple one before, but it just wasn’t good.

[Jaz]
It’s good you’ve got the good stuff. I would say use it more, but when you next have some direct restorations, please, I really want you, cause you’ve got all the time in the world as a student, right? I want you to go through that difficult period of using rubber dam, quadrant, isolate the quadrant, watch my webinar. I’ve got 30 videos on Protrusive Guidance. It’s like five minutes, 15 minutes of cases I really struggled in, unedited raw footage of me putting on rubber dam. Revise all of those.

And I want you to use that technique. And I want you to promise me that you’re going to use rubber dam because now is the best time. You start practicing now. Wow. You’re going to absolutely sail.

[Emma]
Yeah, definitely. I think it’s so frustrating, but once it’s on, it’s good. And once you’re good at it, you’re good at it, you know.

[Jaz]
Buy a packet of flossettes, cause maybe you don’t have it in clinic so take your own flossettes with you, okay? You got the unodent rubber dam, which is great. And follow the instructions in those videos and the webinar. Trust me, like you’ll have such a less frustrating time.

[Emma]
Yeah. And hopefully I get to do some indirects.

[Jaz]
Even just direct. I want you for, you know, comps, for your comps as well. That’s where you practice.

[Emma]
Yeah, yeah, definitely. And they’re quite big on rubber dam in Glasgow, so it was good. My next question that I did want to ask you, Jaz, was about intraoral scanners. We have one in the dental hospital to let the students play with. I’m sure it’s on the staff clinics, probably.

[Jaz]
I can imagine all the things the students have been scanning.

[Emma]
Yeah, taking us like half an hour.

[Jaz]
And then lose the handle, it’s a funny thing.

[Emma]
Yeah. Do you think, like in your practice, like in your surgery, Is an intraoral scanner like an essential for you, or do you think it’s very much possible to achieve the same results with traditional impressions?

[Jaz]
Oh, I mean, impressions are king. Like, impressions are great. But the question really should be switched. Is it possible to achieve the results with digital that the good results we’ve always had with analog? And the answer, I think, is yes, in most cases, but you have to remember a few rules. When you’re using something like silicon based impression materials, because the flow of it, it can go under the sulcus, it can capture the details.

With a scanner, you can only capture where the light goes. And so with digital techniques and scanning, you need to be more aggressive with your retraction, with your retraction cord, with your suppression of the tissues. Tissue management becomes more complex when you go digital. Tissue management, it’s easier because the light bodied silicon will flow in those areas and will save you.

So analog is amazing, but digital with these quality scans, I mean, like prime scan, that kind of stuff. They’re really, really great. I use a scanner, which is not that as good for restorative. I use the iTero. I don’t care if I’m saying brands and stuff. It is what it is. They’re good for Invisalign and that kind of stuff.

But the one I use at the moment, It’s not wonderful for restorative. I’ve been using it fine. I just have to then take extra time and really suppress my tissues and try and spend what time get as the best scans I can. When it comes to sub gingival areas and especially vertical preparations, You know, I went on Marco’s course in Sicily and he showed me my own scan.

Like the, what the technician sees with his scans is sometimes it will make you cry. Impressions for subgingival areas and vertical preparations is still king and scanners are still catching up. But for things that are supra gingival, scanning accuracy and the ability to produce really good restorations with a good fit is fantastic now. So it depends on now if you’re working subgingivally or super gingivally. The answer is scanners are pretty much there, but they still have a bit more improving to do.

[Emma]
Yeah. Do you think impressions will ever, I don’t know, not not be a thing?

[Jaz]
I think eventually they’ll be phased out. I think so. I mean, the amount of impressions, I would love to speak to a technician and find out the amount of technicians that are getting in analog work. And what percentage of that work it is. I’m sure it’s declining rapidly at the moment. I’m sure there’s still niche scenarios where impressions are king and analog is king, but most indications, even dentures are going very digital, believe it or not. So digital is the way forward. There’s still the few, sometimes you use your analog to compliment your digital. So I don’t think it’ll be fully obsolete, but I think they might be five, 10%, whereas the digital will be the 90%.

[Emma]
Well, that’s good. Cause I’m rubbish at taking impressions.

[Jaz]
You’ll be rubbish at scanning as well. You think it’s easy. iTero scan, I took, like, took me like half an hour. Now it takes like three minutes, but it’s like a steep learning curve with everything.

[Emma]
Yeah, definitely. But, no, that’s interesting. That’s interesting. The last thing I did want to ask you was about the lab and I know that you’re very specific with your labs. You’ve got great communication with them. Like, are there specific challenges or preferences that you have when working with labs on ceramic restorations specifically?

[Jaz]
It’s a journey you go on with your technician and a great piece of advice that was given by my technician, Graham, who came to the podcast a few times is try and find a technician who’s like a similar age to you and you work together and you send all your cases to that guy or gal and then you communicate over WhatsApp and you grow together.

There’s something really beautiful about that. And then dentists, when I say to dentists that I helped to train my technicians to improve this element of it, they think, but you’re a dentist. What do you know about the technician side? How can you train them? But when you speak to a technician, they’re very grateful.

Equally, the technician trains me. And he tells me, he shows me my scans at all. You know, you should have smoothed this amalgam in the mesial, like you didn’t. And it’s made it more difficult for me and you’re constantly learning together. So firstly, the lesson here is communicate with the technician, even if you’re using a bigger lab and you don’t even know the name or the face of the technician that’s making it work, the more information you give them, the better.

So if you just say Emax crown, A3 upper left six, okay, how much care love and attention do you think the technician will give they’re just going to put the bottom of the pile and they’ll make you something that’s acceptable. Hopefully. If you say lithium disilicate, overlay restoration upper left six shade A three, but it’s got hints of a higher chroma cervically. My mesial margin was a bit questionable.

Please let me know if it was acceptable or not. Please give me some feedback. Okay, so you’re inviting them to give you feedback. There were shim stock holds on the upper left first premolar, second premolar. The second molar wasn’t holding shim, but the third molar was. So now I can verify the bite. Okay.

And then you say that please follow the cuspal inclines of the adjacent teeth because this patient’s got group function. And I’d like to keep that because we’re not changing anything about that basically. Try and aim for a couple of contacts with the opposing tooth, where you see the cusp of the opposing tooth, try and create these landing areas in this molar. And so when you give all that kind of information, All right, you’re going to get something much better back.

[Emma]
Yeah, yeah, and who I have on a Friday morning on my Pros clinic, Mr. Fogel. He was a dental technician before he was a dentist.

[Jaz]
They are the best dentists.

[Emma]
And he, yeah, he loves Pros. He loves it so much. And we were doing a tutorial about lab, some, I can’t remember what it was about, anyway.

[Jaz] I have no idea what it was about. It was something I just showed up hungover. It was-

[Emma]
He was talking about inviting your lab technicians to critique you and vice versa. And just about like-

[Jaz]
Some technicians are scared to critique their dentist because they’re thinking of losing business, losing a client. But when you give them from the get go, from the get go, I tell Graham, listen, don’t beat about the bush with me. If I’ve done something not to your standard, you gotta tell me. Equally, when you cock up, and he does, and I cock up sometimes, and you know, when he drops the ball, I’ll tell him.

I’ll send him, because I’m recording my videos of me doing the procedures, unfortunately, he gets the crudest feedback. He sees me struggling to fit the crown that he made, and he’ll see that, oh, yep, I kind of overdid it on that medial contact, and he gets to see video footage, or very rarely, but sometimes I reject a crown, because there’s an open margin there.

And you get to see my photos and videos. So it’s painful being a technician sometimes when you’ve got the clients like me, but equally when I’ve done something wrong, he’ll tell me, and it’s a beautiful to grow like that. And our mistakes are getting less and less. And we are able to really serve our patients better.

[Emma]
Yeah, definitely. And I think it goes both ways. Like, I think dentists, well students anyway, are often scared to speak to their lab or if something’s not gone quite right to talk to them about that. But Mr. Fogle was saying, he’s like, if you phone up a lab, he’s like, I’ve never spoke to some, a technician on the phone that wasn’t very pleasant. It’s like, no one wants to lose business at the end of the day and you want to have a technician. So yeah.

[Jaz]
I was always taught that a average dentist and a good technician will do very well. So pick your technician wisely. Pay a little bit more premium for your technician basically. Get a good technician and they will save your bacon.

[Emma]
A hundred percent. And I think that’s all the questions that I had to do, Jaz.

[Jaz]
Thank you so much. And I’m excited for you to, A, start doing some rubber dam dentistry. I would love for you to do it and feedback, see how it went. And yes, but first, a hundred times you’ll be frustrating, pulling your hair out.

And the hundredth first time you’re like, you know what? Today I isolated and I didn’t cry while isolating. It was good, right? So you know, you have to go for it, please. You have to go for it. And then also when you start coming to your first indirect restoration, let’s have a chat. Tell me what material you got in mind, what your technician suggested, what your tutor said.

And you’re in this funny position as a dental student where you kind of, you don’t have free mind. You’re kind of led by what your tutor says on the day. And then there might be a different tutor on the day of fit. And they think, what the hell was this initial thing in this life? And that’s how it works. Embrace it, enjoy it, embrace it. As long as you’re there, like a sponge learning, you will fly.

[Emma]
Yeah, for sure. Like, I’ve been frustrated a couple times with treatment plans changing, different clinicians like, pick their brains about it. They’ll all have different opinions and that can be frustrating at the moment and maybe for the patient as well, but it’s like a goldmine of tips and tricks to pick up on. Just pick everyone’s brains whilst you can.

[Jaz]
It’s important. So whenever someone changes a plan, that’s totally cool. But can you say, hey, Mrs. Smith, like, I see that you changed this from a filling to a crown. Or, use the other way around, crown to a filling. May I ask the rationale behind that so I can learn this a bit more?

And then just, yeah, listen and learn and you know that everything is justifiable. There’s no hard and fast rules and dentistry. You can just justify everything as long as there’s a good why and a good reasoning behind it.

[Emma] Yeah, for sure. And I can’t speak for any other universities, but I think dentists that are in education, like they’re all a bunch of nerds. Like they want to talk about it. They want to be asked why they love talking about it. So they will stand there and show your ear off for 20 minutes if you want them to.

[Jaz]
And you know what, sometimes they just want, like, sometimes it’s a wish that students were more receptive and not on their phone. And sometimes if you’re there to listen, they will give you something. If they suss out that you’re actually really keen. Like, they will give you everything. Like, if you show that enthusiasm and keenness, you will really gain a lot. So, keep that in mind, guys.

[Emma]
Definitely, definitely.

[Jaz]
Great, Emma. I hope you have a, okay, by the time this comes out, maybe after Christmas, but happy Christmas, happy new year, and I’m excited to grow together in 2025 and inspire students all over the world. This month’s notes were ceramics, right?

[Emma]
Yes, ceramics, yes. So those protocols that we’re talking about, air abrasion, acids, all those sorts of things, different materials, when, when not, you would maybe use them, all those sorts of things.

[Jaz]
Great, and do you remember how many pages it was?

[Emma]
I don’t actually, no.

[Jaz]
I saw it was very comprehensive, lots of pages basically, but like lots of good stuff, very visual, nice protocols. So remember students, email student@protrusive.co.uk to prove that you’re a student. We’ll add you to space and you can access the crush your exam section where all the notes are written by Emma.

Any images that we take, we always reference them, which is really important to say thank you to all the people because it’s difficult to generate these images sometimes, but we always reference where we got them from. And I think what we’re building here is a really fantastic resource. So, Emma, thanks so much. Keep up the good work and I’ll catch you soon.

[Emma]
Perfect. Thank you.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end, as always. Thank you to Emma and Team Protrusive. Without the team, I would be totally burnt out. The podcast would have died years ago, but it’s down to you guys, your comments, your love and hard work and dedication from the team that allows Protrusive to continue and thrive.

We’ve got so much planned for 2025. The most happening place to be right now is our Protrusive Guidance app, our community of the nicest and geekiest dentists in the world. That’s where you ask your questions that you feel embarrassed to ask anywhere else, and you don’t need the anonymous function.

There’s so much toxicity on Facebook groups, but not on Protrusive Guidance, because you, listening right now, watching right now, the fact that you made it this far, it means that you’re definitely very geeky. And you’re probably very nice. If you identify yourself as a Protruserati, I’ve realized that you guys are just amazing people.

And so come and join your tribe on Protrusive Guidance. That’s protrusive.app to join in. For those of you on a paid plan, you can get your CE certificates. Just answer the questions below within Protrusive Guidance, and Mari, our CPD queen, will sort you right out. Oh, and don’t forget to like and comment below.

What other topics would you like covered? Thanks again for watching to the end. I’ll catch you same time, same place next week. Bye for now.

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