Discoloured Centrals Incisors with Jason Smithson – PDP191

Protrusive Dental Podcast

The secret to success with non-vital bleaching is knowing when it’s not going to work.

Dr Jason Smithson shares his decision making in discoloured incisors AND the protocols he uses in their management.

When is a purely restorative approach more appropriate than bleaching?

When is ceramic preferred to composite?

What is the best way to mask a metal post?

https://youtu.be/r59gt8g1niU

Watch PDP191 on Youtube

Listen/Watch this episode which reveals all! This episode is eligible for 1 CE credit via the Protrusive Guidance platform.

Protrusive Dental Pearl:

To help achieve great shade selection, take pictures sequentially during your assessment and throughout the procedure, then edit the pictures to show as black and white. By analysing the shade match through a black and white process and in steps throughout the treatment, the shade selection will be far more accurate than just attempting this once at the beginning, especially without using the black and white technique, as this will emphasise the value of the shade

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

Highlights of this Episode:
01:56 Protrusive Dental Pearl
03:15 Introduction – Dr Jason Smithson
05:30 Biomimetic Dentistry
14:50 Non Vital Bleaching
24:55 Calcific Metamorphosis
28:30 Ceramic or Composite Resin
31:17 Deeper Dive into Ceramic Use
32:55 Composite veneers
40:35 Perfecting Shade
43:40 Jason’s Courses

Access the CPD quiz either on your browser or by downloading our mobile app. For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you liked this episode, you will also like The ‘Anti-Biomimetic Dentist’ – Restorative Lessons from Pasquale Venuti Part 1 – PDP152 – Protrusive Dental Podcast

Click below for full episode transcript:

Jaz's Introduction: One of the most common questions we get on Protrusive is how do you manage the discoloured central incisor? Now, we already have episodes on the non vital bleaching technique.

Jaz’s Introduction:
In fact, it’s a two part absolute ripper. But sometimes we experience relapse or we find a case where perhaps it’s too risky to try non vital bleaching and we want to manage this restoratively.

So I brought on once again, Dr Jason Smithson you probably already know who this is If you don’t you probably live under a rock somewhere. He’s one of the greatest dentists ever and he’s taught me so much of what I know. I’m constantly learning more and more from him. In fact, even in this episode, he taught me so, so much. I know you’re going to gain so much from this.

Hello, Protruserati. I’m Jaz Gulati, recording at my in law’s place at the moment, in the loft, because it is half term. The kids are off, but I so badly wanted to record this. So my wife has given me a permit to do this podcast with Dr. Jason Smithson. The kind of themes you cover are when do you know not to even attempt non lethal bleaching, and perhaps a restorative technique will be better?

When to veneer versus when we should actually be crowning. I know crown is like a dirty word, but actually, you’ll see that there is still a place for the crown. Revisit the composite versus ceramic debate when it comes to restoring that discolored central incisor. And this entire episode is sponsored by Sprinkled With gems and pearls from Jason.

Denta Pearl:
The Protrusive Dental Pearl I have for you is taken from this episode. Now, you may already be familiar with the protocol of taking a black and white photo of the anterior teeth that you’re restoring because it helps you to appreciate the value, the brightness of the tooth. And sometimes we use the composite button technique. I.e we put a small little button of composite on the facial of an incisor to see which button of composite, different shades of composite best matches the shade of your tooth.

Now, if you listen to the end of the episode, Jason will share the common mistake dentists make all the time that he sees on social media when we’re doing the button shade test for composite. But when it comes to the pearl, the pearl is the whole beauty of the black and white photo and not just using it at the beginning.

But actually using it intraoperatively or perioperatively. What I mean by this is when you’re actually painting on the different layers of composite, let’s say using an opaque layer first, instead of just proceeding and looking at the end, why don’t you take a black and white photo, or get your assistant to take a photo, even on their iPhone.

Take a photo, quickly convert it into black and white, and have a look. Has that shade of composite that you just placed given enough value? Do you perhaps need to add a little bit more? It’s valuable real time data that you can get by the use of the black and white photo. So I’ve been guilty of using this technique at the start, but not using it as I’m building my layers up.

Especially if you’re trying to mask a discoloured tooth. So next time you’re in this scenario and you’re using like an opaque type of composite, use this technique of sequential black and white photos to help you decide if you’ve got enough thickness of composite.

This episode will be eligible for 50 minutes of CPD by answering the CE quiz at the end. Let’s now join Dr. Jason Smithson. And we actually start off with Jason’s biggest bugbears. We talk about his views on biomimetic dentistry and posts. So please do enjoy that. But if you’re particularly waiting for that content on purely discolored teeth, then you may wish to skip the next 8 to 10 minutes.

Main Episode:
Please do introduce yourself to those who, few people haven’t heard of you.

[Jason]
Yeah, so my name’s Jason Smithson. I am a general dentist. I’m based in a practice called Revitalise, which is in Cornwall, just outside Truro, in the extreme southwest of England. So, if you’re not based in the UK, if you think of the UK as a triangle, and at the top of the triangle would be Scotland, and at the bottom right would be London, and then on the bottom left, just below Wales, and just sort of below Ireland, is Cornwall where I live, so it’s kind of closest to the US.

And in the practice, I’m technically a general dentist, but I just really do restorative dentistry, crown and bridge work, adhesive bridge work, implant restoration, I don’t place implants, but I restore, perio surgery, and something which I’m mainly known for is composite bonding, which I’ve been doing for 25 years now, which is quite a long time, but there we go.

So that’s kind of me and that’s what I do. I also have a very small medico legal practice. I do mainly defense of dentists and the odd personal injuries case. Not a huge amount of my workload. And a larger part of my workload is teaching, and I teach roughly 100 days a year, give or take. So, and have been doing for 15 years, so that’s kind of me. So there we go.

[Jaz]
Amazing. I mean, I’ve been to many of your courses and I’ve learned so much from you. Either through some recorded content that I might have seen online or your live courses. So I can highly recommend if you haven’t learned from Jason for whether you’re on stateside UK, around the world, Jason does post up his photos of his shoes up against the train station a fair bit.

So I know he travels around. So if you ever get a chance to see Jason teach, please do take that up. Interesting thing off script, off script, Jason. You mentioned about your affinity towards adhesive dentistry. Would you identify yourself as a quote unquote biomimetic dentist? What are your thoughts on this terminology?

[Jason]
That could be on script if you like, I don’t mind. Well-

[Jaz]
We’re definitely airing this. It’s just that it’s something I didn’t prepare for.

[Jason]
Okay, so I don’t mind biomimetics as a term, actually. I think it’s kind of okay. But really, all we’re doing with biomimetic dentistry is really using operative dentistry techniques, preparation techniques really, and the materials we have at our disposal currently.

Glass ionomer, composite resin, ceramic, pretty much. Silver amalgams dying out. To the best of our abilities, to restore teeth so that they A. Look good. B. Function well. And, really importantly, last for a decent amount of time. And keep the patient’s tooth in their head which is really what our job is. And if you want to call that biomimetic, then-

[Jaz]
Jason, how does one make the distinction between Adhesive Dentistry and Biomimetic? For me, when I interpret it, I think when I read everything about biomimetic dentistry, it is pretty much adhesive dentistry.

[Jason]
It’s a buzzword, really. It’s a kind of cool and trendy thing to call it, but really it’s just good quality operative dentistry. The original term was coined in so much as there was a kind of a move towards trying to replicate enamel with ceramic and composite resin with dentine because the properties of ceramic are perhaps a little bit more like enamel and the properties of composite are perhaps a little bit more like dentine, but I don’t really buy into that.

That’s just BS really, because if you think about composite resin, it isn’t remotely like dentine, firstly, it’s not vital and it doesn’t have collagen fibrils, et cetera, et cetera. And then we’ve had the whole. And please don’t take this as I’m anti fibers in dentistry, because I’m really not. But then we’ve had the whole thing about, oh, we can use fibers and make it more like collagen.

I’m like, really? I think it’s okay as a general term, because if you talk about biomimetic dentistry, I think most dentists know what you’re talking about. So it’s a descriptive word. So as a descriptive word, it works very well. Because it communicates. But from a scientific point of view, I think it’s a little bit invalid.

I also think that some of the things we do in biomimetic dentistry actually, actually overcomplicate the procedures. And as a result of overcomplicating the procedures, make it more likely that you’ll make an error in one of the steps, and therefore make it more likely that the restoration will fail earlier, which is not our primary function.

A good example of that, for example, would be using fiber technology in a smaller class 1 lesion, smaller class 1 cavity. So there’s a big move now toward placing fibers in the base of a smaller class 1 cavity, and the reasoning for that is it reduces, well, oftentimes you see it, promoted as reduces C factor, that’s not the case at all.

It reduces the impact of C factor, which is quite different. Reduces the impact of C factor in laboratory studies. And is that clinically relevant? I don’t know. Nobody’s really done the studies. And yet it’s really, really heavily promoted. Now I’m not saying it’s a bad thing to do if you do all the steps really well.

But what I am saying is for the average dentist, and we have to accept that in terms of ability, there’s a bell curve. The vast majority of us are average. I’m certainly average when it comes to endo and things like that. Making it more complicated is actually a bad idea because you make more mistakes, it’s going to take you longer for starters, so it’s going to be more expensive for the patient, so it delivers less care to fewer patients, which is no good.

And also, you’re more likely to get a poorer longterm outcome. So actually I don’t see that as a strong move forward. You might consider using fibers in larger cavities and there might be valid reasons for that. But I think some aspects of it are really over act. So there we go. I mean, the other one, which drives me, here we go.

There’s a rant, the other one that drives me a little bit. Nuts is when a patient comes with a, well it’s kind of relevant to the discolored central, a discolored central, maybe endo treated and maybe it’s got a class 5 and maybe it’s got a class 3 and maybe it’s got an endo access and we get bits of composite added and then a ceramic veneer.

Why don’t you just do a crown? And then there’s the whole, and in that same scenario, it’s like, oh, you mustn’t, you would be arrested. Call the police if you put a post in the tooth. Because that will cause the tooth to fail. Well, really? I have objections to cutting a prep to put post in. When I first qualified in the early nineties, we used to stick and this is no disrespect to the brand because I still use the brand nowadays, but you stick a parapost bur down an upper central incisor and cut a nice parallel siding prep and then cut, you probably don’t remember this, but then we also used to cut a lock into the coronal aspect.

I wouldn’t do that anymore. But to use your existing endo access and to put a post in there, what’s the downside of that? You haven’t done any more prep and you’ve got something that is pre polymerized, if you’re using fiber post, or doesn’t need polymerizing if you’re using a metal post, and you’ve bonded it, or there’s a modified glassonomer in situ, it’s taken up the space and obviously it’s got a mechanical advantage to the tooth.

And nowadays you see people putting lots of fibers down and I’m like, why would you do that? That looks really difficult. And from an engineering point of view, just doesn’t work. And like, I’m being told that post fracture teeth. Well, I’ve been in the same practice with the same patients in the same small town since 1997.

And yeah, I get teeth fractured with posts in situ, but not very commonly. If you’ve got adequate ferrule. So, getting right back to the original question, I think biomimetics is a good term in summary. Because it helps people understand what we’re talking about. But I think we’re using it to do quite weird non evidence based things.

Which have now really, really scarily become mainstream. And the reason why they’ve become mainstream is really social media, because this is another one of my bug bears. If something gets a lot of likes on, for example, Instagram, and again, I’m not picking on Instagram. Could be TikTok, could be Facebook.

If something gets a lot of likes on Instagram, it’s instantly accepted as being a valid approach. Well, that’s not how science works. If something is valid, then really it should be evidence based and have proper prospective trial. Well, it should have lab trials first and then proper prospective trials on patients.

And we’ve moved away from that. Indeed, an example of that would be I gave a presentation, I won’t say where it was, but in Europe three months ago. And I presented something and somebody put their hand up in the audience and said that’s not true. And I said, okay, fine. This is cool. This is really good.

We can have a discussion about why this ever so slightly contentious issue may or may not be valid. And I said, so here’s my evidence. I’ve already presented it in the slides. These are the lab studies. These are the clinical studies. This is my experience, which I’ve been doing this technique for 12 years.

And these are my failures. And I admit my failures. What is your counter argument? And it was like, well, this guy on Instagram, who’s got 200, 000 followers says to do it this way. And I’m like, yeah, that’s okay. He might understand the science. Probably does. And he probably understands it better than I do.

And he’s probably got follow ups, but that’s just not science. And that’s the way we’re going. And not to pick on biomimetic dentistry, but it does seem to be seriously biased towards biomimetic dentistry. So there we are.

[Jaz]
I guess if you only listen this far, then you can call this episode Jason Smith’s bug bears and so far I’ve enjoyed every one of them because I think you speak the truth and you’re very much direct. And I think that’s good. I think it’s a nice reminder. That there’s a lot out there, and to be critical of everything you see and you read, and always rely back on, okay, where is the science behind this.

[Jason]
Yeah, I think, I think on the flip, we can be over reliant on science. Like, I’ve also been in fairly academic meetings where I can remember one on perio, a while back I was in, and a guy presented his 40 year retrospective.

In other words, what happened to his case is using this technique over 40 years and somebody counter argued it with a scientific approach, a prospective trial, but the prospective trial is only of 12 patients. So, like, there’s this double blind prospective trial which is actually the pinnacle of scientific evidence.

But with only 12 subjects. Versus this guy’s really anecdotal opinion. He hadn’t done very much other than audit it. But it was literally thousands, if not tens of thousands of patients. Which is actually, anecdote is the bottom end of scientific evidence. Which one is the most valid there? Now, I’d upend it and think, well okay.

I’m more inclined to believe this guy. Although it’s skewed a little bit, again, because he’s got really good hands and people who have really good hands can do things that are often not quite correct and get away with it, so, there’s a lot to think about in science. Really, if you think really critically.

[Jaz]
And then let’s apply this to the theme that I want to cover today, which is the discolored central incisor and I’ve specifically given you this scenario in this task because I have covered before on the podcast about non vital bleaching and particularly I want to just get like a couple of minutes on your take on non vital bleaching because there are some clinicians that I know who are not big fans of it because they’ve done it and then they’ve seen the recourse come back and they’ve been disappointed with relapse.

So, do you think there’s still a place for non vital bleaching or have you found that to mitigate the risk of relapse if you skip the non vital bleaching and just mask the discoloration with a restorative material, therefore negating the risk of relapse? What are the circumstances which you may or may not consider that kind of an approach?

[Jason]
Yeah, so it really depends on the literature you look at, but when you look at the literature, the relapse rate is probably hovering around 50 percent. But which is for a medical procedure not that great. But if you actually read the papers and I actually have because I’m a bit nerdy like that. You will see that the patients were just selected on the basis of having a discoloured tooth and there are lots of diagnoses of discoloured teeth, if the patient’s had an amalgam in the palatal surface to fill, the access cavity is discoloured.

Sometimes it discolours as a result of blood in the dentinal tubules at the time of trauma, et cetera, et cetera. One of the causes of discoloration is something called CM or calcific metamorphosis. And what that means is when the tooth is traumatized. The pulp reacts by laying down dentine, it’s a healing response.

And what you see on that patient is typically either a yellow or sometimes a brown discoloration. And that’s as a result of having less pulp and more dentine. So that’s one part of the diagnosis. The other aspect of the diagnosis is when you take a radiograph, particularly for like an upper central or upper laterals, you will see the pulp chamber of the affected tooth is significantly smaller, or nonexistent in comparison to the pulp chamber of the non affected tooth.

And sometimes these teeth are vital. So let’s pretend it’s got calcific metamorphosis and is non vital. I’ve heard people say other things, but anecdotally, going back to my own anecdotal evidence, and my data is off the top of my head the last time I checked, which was Christmas time ish.

I’ve done something like about 800 cases over the last 15 years. My outcomes for calcific metamorphosis were quite poor. And got relapsed fairly rapidly, usually in the first one to three months. So going back to the original papers, they didn’t take the calcific metamorphosis cases out.

Because it’s not written up in the methodology of the papers. So what they were doing, what most papers do, is look at discoloration, internal widening of discoloration, including calcific metamorphosis cases. So quite clearly their outcomes, based on my own anecdotal experience, will be poorer. So, I realized this when I was looking at this, gosh, seven years ago or so, six or seven years ago, and what I started to do was to not treat the calcific metamorphosis cases with internal whitening using the diagnosis of orange yellow discoloration or diagnostic features of orange yellow discoloration and smaller pulp chamber on radiograph.

And what I found was my success rates went up, and my success rates are low 90 percent now. So, and that is a long winded answer, but in answer to your original question, I would probably not go for internal widening on an adult, on an older adult patient with calcific metamorphosis, I would probably go straight for the veneer or the crown or the composite resin bonding.

The time I might have a pulp even though in my hands the success rates are 50 percent or perhaps even less, or maybe a child or maybe a younger adult, or maybe you put this to the patient and say, look, you’ve got a 50/50 chance of it working, but the trade off is if it does work, we don’t have to drill your tooth and you’ve got a fairly intact tooth. In that case, I might have a go at it as well, with the understanding of the patient that it might fail. So it’s nuanced, basically.

[Jaz]
I feel like I read this in a Facebook comment that you might have wrote years ago because there are a lot of dentists like me who like to, read what you write. The cases that you post are brilliant. Once, remember, you wrote, and it all makes sense now based on what you’re saying here, but you once wrote that, the black discoloured teeth respond better to internal bleaching than the orange yellow hue teeth.

[Jason]
Exactly. So, that’s where you can be the hero or not. Somebody comes along with a black tooth and because we’re a referral practice, oftentimes they’re referred for a crown or a veneer. And I say to them, well, okay, we can do some internal whitening and actually it will, there’s less drilling. It’s quicker, actually, because you can get it done in three days, two to three days and you’ve got more tooth left.

And you look great when somebody comes with a black tooth and suddenly it’s give or take the correct shade with an orange tooth where somebody come often quite a picky patient. They’ve got a very mild orange discoloration of a tooth which to the average person is barely perceptible. But for them is an issue. Not to say they’re a bad person, they’re just more perceptive.

They’re the ones that are actually more tricky, which is not ideal for us. But they’re the ones you could really be careful with. Because again, also matching the shade with resin or ceramic is also tricky as well. So yeah.

[Jaz]
So is it fair to say that the patients that come in with a necrotic tooth, so the diagnosis is not calcific metamorphosis, it’s a necrotic tooth. And we have a black tooth on our hands due to the discoloration from the bleeding of the pulpal bleeding products, basically, the iron, I believe, in the blood may be responsible for this. Is that the kind of case where you’re going to be bleaching every time? Or do you think there’s a merit in sometimes restoratively masking in such, such a scenario?

[Jason]
So, if the tooth was relatively intact and it might have, for example, a small class four. Which they do, because obviously they’ve been traumatized. Or maybe just an endo access. Then 100 percent I’m going to bleach that without question. If the patient comes with endo access and the tooth has, for example, a class 5 and a mesial and distal class 3, I’m probably just going to put a crown on that tooth. Alright? Because it’s already pretty compromised.

[Jaz]
And skip the whitening, right?

[Jason]
Skip the whitening. Yeah, I’m going to do a crown with a probably a post but no prep of the post space and they’re the two extremes. So you’ve got the really minimally damaged tooth and you’ve got the maximally damaged tooth.

The nuance comes when it’s somewhere in between and then you have to take on board factors such as the age of the patient. You have to have a conversation with the patient and look at their attitude to risk. And maybe look at the other teeth around it. How strategic is that tooth, et cetera, et cetera, et cetera.

Because the patient’s also going to understand if we just stick a crown on the tooth. They’ve got a fairly guaranteed outcome with a good ceramist and with a good dentist. But, we’ve pushed them down that restorative cascade so they’re pushing closer to implant and they’re pushing closer to tooth loss.

And they need to understand that. Now that may not be an issue for them if it’s a 70 year old patient and you’re saying to them, well, you’ll probably get 15 years out of this is quite a different scenario from a 22 year old patient. So a lot of little subtleties to think about.

I think as dentists, we often want this kind of recipe, do this, do this and do this, nuance is it’s human nature, but we as dentists, because we’re kind of technically orientated because of that’s the way we work. We want to kind of do this, then do this and do this, but it isn’t that it’s kind of think of multiple factors and then nuance it with a patient.

[Jaz]
This is what makes our profession an art. I used to really get frustrated by this aspect of dentistry, the fact that if I ask you, you’re giving this great advice, which I really resonate with, but then there are a hundred other different opinions and protocols out there and therefore, for the young dentist who’s learning, trying to find their feet, trying to make their own philosophies and way of practicing, it can become a very confusing field.

So once you start to appreciate that actually this is the beautiful side dentistry, that you can do it so many ways and you start to just flip the way that you see this area. I think a lot of young dentists can get more fulfillment from their profession from being actually there are other ways to it. This one resonates with me.

Listen to everyone and do what feels right to you, but also to do your due diligence and actually look at the studies and look at the method, materials and methods to come up with what’s best for your patient at that particular time of your career.

[Jason]
Yeah, I think I’m certainly not sitting here and saying that. The way I do it is the only way to do it and it’s the right way. It’s just one way that’s worked for me. And as a result of that, it’s made me, in my practice, attract a certain type of patient. Now that type of patient may not be for everybody. So, I mean, there are huge outliers, like some people would just say, oh, take it out and put Implant in now.

That’s quite clearly wrong. But most of the balanced views that differ have validity. And what happens is the dentist kind of plays to their strengths and they attract a certain type of patient, and that’s where we’re at. For the good, actually. Well, I would say if we had a scenario where, everything was like stepwise you do this do this do this it would kind of be like in a factory and then it would be less fun, I think-

[Jaz]
A hundred percent. Yeah. I like that. And so I’m glad we mentioned that I think a lot of dentists, I do repeat this theme a lot about seeing the beauty of it and the artistic side of it. And I think it’s, people message me saying that, you know what we need, we constantly need to hear it to remind us. ’cause it’s a tricky, being a general dentist is no easy business.

So it’s nice to be reminded of that. Let’s talk about this particular type of patient, Jason. You mentioned, you beautifully described this patient with a yellow tooth calcific metamorphosis. You take a PA and there’s pretty much no pulp. I see this now and again as well, and I’ve treated a few of these.

And I really want to know about how you approach the case because there are so many difficulties in this scenario, A the fact that this patient is bothered by a slightly off yellow tooth. So we already have because I know some people who have a black tooth. And they don’t want to do anything about it.

You’ve got a black central incisor. And so that’s the opposite end of they don’t give a damn. And then you’ve got someone with like a slightly off yellow tooth. And so they’re now presenting to you. So you know the expectations exactly. And so this patient now, high expectations. And what we’re trying to do is try to match a central incisor with now restorative materials.

So my one school of thought that I’ve been exposed to through social media, and I’m just being honest here, I saw this on social media from a very, very respectful dentist, and what they did is that they prepped this tooth, this calcific metamorphosis, and one of the points they made is like, we want to get into the dentine.

Because it’s the dentine that’s discolored. Now, by getting in there, you give your restorative material more space. And I think this was composite that was used at that time, basically. You give direct composite. So you give your composite more space and you get to the source of the discoloration.

Because it’s not the enamel that this discoloration is coming from. So, your views on generally the different ways that you might approach such a case to get the restorative success. And B, what do you think about this approach of this particular dentist?

[Jason]
Well, I can kind of see his argument, but I don’t, I see the argument, but I don’t see the logic in so much as yes, the discolouration is localized to the dentine, but by cutting more tooth away. What you’re going to do is make the tooth more flexible, more bendy in function, because if you take the enamel off, the enamel’s a stiff bit of the tooth that makes it more rigid. If you make it more bendy, it’s going to do one of two things. Either it’s going to fracture, or as it bends, the tooth bends in one way, and the restorative material, be it ceramic or composite resin, bends in another way.

And the failure will be at the bond between the two, and it will usually delaminate. So, my thoughts are to restore that tooth as conservatively as possible. In other words, don’t drill the hell out of it. On the flip, you have got room to drill the hell out of it if you wanted to do a crown, because the pulp’s quite small.

So there’s that. My approach would be to restore that tooth in as conservative manner as possible. Now, if a veneer is indicated, You’ve got the option of composite resin or ceramic. And if a crown is indicated, you’ve obviously got the option of ceramic. Let’s put the crown to one side for now because that’s less debatable. The only thing I would say-

[Jaz]
I think let’s focus on veneer. You’ve already said that whitening in your hands in this day and age is not what you’d go for. So we’re going for the restorative option. And so really it’s a toss up. And one of the side questions is, when do you go ceramic?

When do you compsite? And then I also want to know about prepping and also about the different opaquing techniques, because I’ve seen some of your cases have been amazed in the use of different opaquers. And so try and find out your experiences and different recipes that you might tried.

[Jason]
So if you’re going down, we’re going to come into tons of nuance here, and is based on skillset of both yourself and your technician, give or take, and your access to certain composite resin materials. So the bottom line is, if you’ve got a superb technician, and if you have really good hands, probably the most conservative approach will be ceramic.

Why? Because ceramic has better masking abilities than composite resin irrespective of what anybody tells you. I’m a composite resin guy. I teach composite resin. It’s really in my favour to tell people composite resin is the panacea for everything. But actually, in this case, if you’ve got a very, very good technician, ceramic is going to be your best option.

Now, the only problem with the ceramic is you’ve got a prep appointment and you’ve got a fit appointment. Now, if it’s a single central, even my ceramist Paul Luke, who’s based in Cornwall, is a superb ceramist. But, single central with Paul, and even with the patient seeing Paul for the shade, and oftentimes the veneer or crown being customized by Paul, chair side, might take us two or three goes to get it dot on.

Particularly for a very fussy patient. So what we’re talking about is three or four visits probably for a patient and you’ve got an A, bill for that which means the cost rise a lot in comparison to a regular single crown or single veneer. B, the patient’s got to have the time to do that. So all things being equal and if the patient’s got the financing, you’ve got the hands and the technician’s got the hands.

And the patient’s got the time, then probably I’m going to go down the ceramic route. Now, most normal dentists who work a normal practice, who do ortho, endo, composite resin, exams, blah, blah, blah. They, they’re not using that level of lab. So probably their outcome with the lab is not going to be as good. So that may skew them down the composite resin route, maybe. So there we are. It’s really related to timeframe, budget and skill of lab technician.

[Jaz]
So I like that approach in terms of assessing one’s ability and which environment you’re working in to decide between composite and ceramic. And more dentists than not who are listening to this, general dentists around the world will be at a position more than likely that they’re going to say, okay, I want to tackle this with composite, right?

So before we now go down the composite pathway, the geeky questions I have about the ceramic is, how thin or how thick is this? Obviously, we’re talking about an aligned teeth. So we’re not dealing with a retrocline incisor that we can bring out. We’re talking about an aligned tooth.

How much prep are we doing, i. e. how thick will the veneer be? And, in your experience, is it a particular ingot of lithium disilicate or is it feldspathic? What do you found as the restoration ceramic of choice in such nuanced cases?

[Jason]
Yeah, so it very much depends on how discoloured the tooth is, nuance again. But you’re probably realistically looking at somewhere between 0. 7 of a millimetre reduction, which is quite chunky, particularly at the cervical. Particularly if it’s endodontically treated.

[Jaz]
So we’re going to be into dentine in the cervical, but the enamel is more in the coronal.

[Jason]
If you look at Shillingburg and Grace, that’s the research on the thickness of enamel at the cervical, it’s 0. 3. There’s just no way you’re going to mask in 0. 3, even with a world class technician is just not going to happen, which again might be another reason why I might go down the crown route rather than a veneer route because I’m prepping quite a chunk off the facial and the ingot. I would probably be using something like for most of the cases, and again, because I’ve got a talented ceramist.

We use the MO ingot, the medium opacity ingot, and that’s something you need to specify because most labs will use the LT ingot, low translucency, and the reason why they use that is it’s easier to handle for the lab in terms of layering and stain and glazing, but we occasionally will use the HO ingot, which is high opacity, but to be on it for veneer, but to be honest, if we’re doing that much prep and the tooth is that dark, oftentimes we’ll be doing a crown anyway, So then we can go back up back one and we may even go down the zirconia route if we’re doing a crown. That’s probably a lecture in itself.

[Jaz]
Okay, brilliant. So that really helps with the ceramic nuances. Now let’s go down the final segment of the podcast then. For a composite then, how much prep are you doing and how does that differ? How does the prep of the composite, direct composite veneer, differ from the prep that you’re sending to your technician for a ceramic veneer?

[Jason]
It’s broadly the same. So you need to prep subgingival. You need to prep somewhere between 0. 3 and sometimes even 0. 5 if you’ve got the room, into the sulcus, otherwise you’ll get grey. You’ve got to prep into the contact points, otherwise when a patient turns to the side you can see a line. And you’ve got to prep some off the facial, perhaps again 0. 7 to 1mm. Now you can get away with it a little bit more with composite resin at the cervical.

By using a lot of flowable opaquer, the only downside with it, so you could do less prep and use more flowable opaquer. The only downside, and if you look at mine, I’m guilty of this myself, they look a bit dead in the gingival third.

Because there’s not so much regular composite resin and there’s a lot of flowable opaquer. And the reason why I’ve done that is to mask it and to get value or brightness and to lose chroma, lose color. But the trade off is it looks a bit dead. And if a patient has a low lip line, you can kind of get away with that.

[Jaz]
And so, you say that it looks dead, but yeah, just to emphasize to everyone, the reason you’ve done that and it’s an informed decision from you is because you want to prep less. You want to be conservative as possible in that area, which makes total sense. And so there’s a trade off that you make.

So I’ve seen Pink Opaque by Cosmodent and there are, I’ve used Ivoclar’s White Opaque in the past as well. Do you have a preference in terms of which flowable opaquer that works well in certain scenarios?

[Jason]
Yeah, I mean, a lot of companies make good ones. Tokuyama make good one. Kulzer make a good one. I kind of like the Cosmedent ones. And the reason why I like the Cosmodent ones is because it’s one of the few companies that actually make the opaquer in a vita shade. Most companies have the opaquer, which is usually kind of white. And if you’re not careful, what you can do is you can end up losing chroma, losing color, and increasing value, increasing brightness on a discolored tooth.

And starting off with a tooth that’s dark and low value but ending up with a restoration that’s too high value so the restoration will really stand out be too bright if you’re not careful whereas with the Cosmodent ones they have the A, B, C shades so if you have for example the surrounding teeth of for example A2 you would use Cosmedent’s A2, A2. 5 opaquer.

And then the base shade, once you’d have picked out the discoloration, would be A2, which makes it a lot more simple, rather than it being a bright white. The pink, which you alluded to, is actually to get rid of grey. So that’s quite useful over the top of, for example, posts. Or, if you’ve got, less common now, but a fractured PFM bridge, where you’re trying to restore the composite, and get away, and hide away the metal.

It works very well, but again, pink on its own, is often too bright. So if I’ve got a grey discoloured tooth and I’m going down the direct resin route what I might do is use a small amount of pink opaquer but maybe add in some of the what we call chromatic opaquer so say the teeth were A2 and the tooth was grey, I’d use maybe one part of pink to maybe three or four parts of A2, A2. 5, mix them together and then I get the brightness of the pink to get rid of the grey you see?

But I also get the chroma, the color of the A2 to match the surrounding teeth. So that’s a lot of people just pile the pink on in one hit and that’s a bit of a mistake. Another option to make it a little easier is to put the pink opaque on in a couple of layers and then put the A2, A2. 5 over the top of that. That works as well.

[Jaz]
It’s a good little tip to think about this different stages of doing it and mixing two different types of products where they’re different qualities. And even just to mix them together. That’s pretty cool. I like that. And recently what I did, and I don’t know if you approve of this, Jason, but bringing back in the series, am I naughty if?

So, here’s something I did recently on my principal. He had a discoloured central incisor and I got a good result. Actually. I’ll put the photos up now in the podcast. So we’ve got a good result in the end. But what I did is I got some composite. This was like Estelite Asteria. I think this was like NA1B, but his adjacent teeth he’d been whitening were just a higher value.

So what I did is I got my composite and then I got some white tint liquid and I rubbed my composite into the white tint. So I let the composite absorb. The white tint, if you like, it wasn’t like pools of it, just like a few drops. And that worked well to lift up the value. And then I used it and then I covered it with some enamel.

It worked out well, but I don’t know. I feel a little bit uneasy about doing this because I don’t know how much it will affect the physical properties. Is this something that is known or is this something that’s a bit frowned upon?

[Jason]
I’ve heard it before, but you’ve got basically two dissimilar materials mixed up and they won’t really mix, what you’ll get is pools of the tint within the resin. One of the things, and again this, I have the luxury of working with a lot of companies and they send me free stuff, so I’ve got tons of composite to play with. I appreciate most people don’t have that option. The Tokuyama product you were talking about is a great product. It handles really well, it polishes superbly, and I love it as a product.

The only downside with the Tokiyama product is it’s designed in Japan, and it tends and I think I’ve been, I think I was the first person to notice this, and I think I’ve been saying it for quite a while, but it tends toward the low value. It tends toward the grayer. And the reason for that is the demographic they’ve tested that resin on people from the far East tend to have lower value teeth.

People from the Far East tend to have more triangular teeth, slightly lower value, and something I really like, which is really cool, is a really strong blue gray opalescence and sometimes even orange effects in the incisal edge. And if you look at a lot of really good, a good example would be a guy called John Chu, who’s a really talented guy from Taiwan.

He does composite resins and they have like really cool blue effects on the incisal edge. And I love that and I wish I could do that on my patients because I just love the artistry of that. But I don’t have the demographic in my slightly boring northern European patient base, and he does in his Taiwanese patient base.

But the flip of that is that Southeast Asian patient base also have low value teeth, and the Tokiyama has been designed for that. So if you take a northern European guy, I’m presuming of principle, who has bleached, Tokuyama wouldn’t be your first choice. You would be wanting to use a composite resin that’s perhaps been developed, perhaps in Germany, because that might be more relevant for that case.

And then you wouldn’t have had to mix the white in. So you probably would have been better off with a bleed shade from, let’s say, Kulzer or Ivoclar or something like that, rather than the Tokuyama. It’s just a thought.

[Jaz]
Very good. I mean, I’ve never heard that before. And so that’s amazing insight in terms of your vast, competent knowledge in different products. So that’s amazing. Well, John already knows this. John, my principal already knows this, but that tint may or may not have been a little bit expired, but anyway, we’ll skip over that. We managed to get a good result on the end. So, but it’s good to know that it’s good to know that there are other ways to it using if you’re not getting enough value, perhaps don’t mix it with tint, perhaps use a different brand.

And so that’s a takeaway there. I know we’ve got a time limit. We’ve got two minutes left. So can you spend a minute, Jason, just telling us about because you talked about the level of prep needed, how there’s a different flowable opaquers, then really the result that dentists get. I mean, aside from the polishing and making sure you get the anatomy right, and I highly recommend they go on some of your courses for that kind of hands on training.

But where the dentist could go wrong now is exactly where I’ve just described that scenario that using the wrong type of composite for the case, they’re not using the right shade for that case. So can you spend just a minute talking about top tips for for dentists starting out and maybe they’re doing this kind of work in terms of how to utilize the concept that they have in terms of shade testing or trying to get as close shade as possible to the case they’re working on.

[Jason]
Yeah, so the main factor is the value of the brightness, and the way to assess that is in black and white, ideally by a photograph. So, once you’ve put your opaquer on the tooth, You need to work out whether you’ve put enough opaquer on, because if you haven’t put enough on, it’s going to end up still being grey.

So what you need to do is to take a photograph of that, import that into your computer, convert that to black and white, and then look at it and compare it with the adjacent teeth, and they should be the same brightness or value. Now obviously in a busy practice, including mine, that’s a huge faff. So what we do is, and most of us have nursing staff who are a bit younger and probably a bit better with IT than we are, I get my nurse just to take an iPhone photo.

So I’ll put a couple of three layers of opaquer on, and then she’ll take an iPhone photo, instantly convert that into black and white, which takes literally seconds, and she’ll say to me, she’ll look at it and go yes or no. And if it’s a no, I put another layer on. Bang. No. Another layer. Bang. Yes. That’s about right.

When she says yes, I’ll have a look at it and just check it. So this is a level of trust and then we move on to layering the chromatic enamel and the effect shade and it’s a much, I mean, I think let’s be clear here from a GDPR point of view, obviously we use a separate iPhone that’s dedicated to this. But yeah, that’s a really good efficient way of doing it.

[Jaz]
Brilliant. So there we have it guys. Next time you’re thinking, hmm, have you got enough a flowable opaquer on or doing the composite button test at the beginning to use a black and white photo, just check out the value there or thereabouts, a good kit. Yeah.

[Jason]
Before we leave, a little take home about the composite buttons. The vast majority I see on Instagram and Facebook are way too thick. They’re composite balls, right? Well, if you think about it, the resin you’re layering is going to be in quarter millimeter layers or less. Right, so if you put a ball of a millimetre or two millimetres of composite resin on the facial of the tooth, that will give you no idea of what’s going on. You need to put a very thin splodge of composite resin, not a big ball, because otherwise it increases, if you put it really thick, it increases the volume of the writer.

[Jaz]
Yeah, and I see this a lot as I’ve done it in the past, but I realised, yeah, very on, I tried to more of a smear now. Rather than a ball or a button. That’s a great tip there. Jason, just so you end the recording. I just love to, I mean, I always put your links and everything, your courses, and they do a bit in Glasgow and around the world and all over UK. Tell us about some up and coming course that you’re getting, that you have the moment, perhaps plan this summer or beyond that, what I think you’re doing, is he doing a diploma, restorative diploma?

[Jason]
Nope, but I have got a course with Kuraray. Which is the first one I’ve done in London for quite some time since pre Covid. And that’s actually at Heathrow Airport, the Radisson at Heathrow Airport. It’s the first weekend in July. And that’s a composite resin course with Kuraray. And then I’ve got some courses.

It’s sold out now, but I’ve got a course next week in Derry with Corsa. And then in Glasgow, we’ve got two courses coming up. One in September. I forget the dates. I should have looked at this in September, which is a-

[Jaz]
I’ll put the links on. Don’t worry. I’ll be sure to put the links in-

[Jason]
September and one in November one’s an advanced composite course and one’s an advanced ceramic course. The cool thing about those courses is they’re three days. And they’re entirely HandsOn because all of the lectures are given to you via a webinar.

So you hit the ground running and you start at nine o’clock on the first day with hands-on, and we finish at five o’clock the last day with hands-on, and there’s no lecture at all. And you can watch the, you can watch the lectures as many times as you like. So that’s where we are on that.

[Jaz]
That’s been a big hit with the community. So, the Protrusive Community, on the app, when we’re chatting and stuff, we often mention you and your courses and that’s been a big hit with those of my cohort, my colleagues who’ve been on your course, and they love the fact that they do the theory webinar wise, and you’re there to help them.

They watch it again and then do the hands on. That’s been a big hit. So guys do check that out. I will put the links there. Jason, thanks so much for covering even right to the end, pointing out little things that we can do to improve the way that we practice our composites and our ceramic work. You’re always a welcome guest on Protrusive, and I just want to say thank you so much for giving your time.

[Jason]
Thanks for the opportunity. Have a really good weekend.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. This episode is eligible for CPD. For example, one of the questions in our CE quiz is, what is one of the main diagnoses that we discussed in this episode that causes a yellow tooth?

Is it A, a necrotic tooth? Is it B, aging? Is it C, calcific metamorphosis, or is it D, molar incisor hypomineralization? I actually had so many more questions for Jason, like there’s so many from the community in Protrusive Guidance, but unfortunately we had a bit of a time limit. But even this topic of discolored central incisors could be a whole day, because It’s a big enough problem.

It’s a real world problem, but I’m hoping what Jason presented to us today, the gems that he gave away, will allow you to be one percent better. Maybe you’re going to start taking more black and white photos, even perioperatively. Maybe you’re going to think about the brand of composite that you’re using and whether it has naturally higher value, because a B1 from a European brand may be different to a B1 from an Asian brand.

Or maybe you’re going to start looking at these flowable opaque composites and have a better understanding of when to use something like a pink opaque, which is better suited to those grayer teeth or masking metal. I would actually love to know what you took away from this episode and any other questions you have, because I know Jason will come back on Protrusive again, he’s always a very welcome guest.

So if you have any questions or themes that you want Jason to cover next time, please do comment below if you’re on YouTube, or in Protrusive Guidance, then please add to the already number of questions that you’ve provided already that we didn’t get to cover today, but we want a bank of questions.

We’re just like a ask Jason series. So we’d love for you to partake in that if you’re on Protrusive Guidance If you don’t know what Protrusive Guidance is, this is our network This is our own social network of the nicest and geekiest dentists in the world. It’s got all of the good stuff of Protrusive on there including our infographics. But more importantly, it’s got you guys, it’s got the Protruserati on there, and it’s just been amazing being part of this community for four months now, before we were on the Protrusive app, which we massively upgraded to Protrusive Guidance, and I’m absolutely loving the search function, the chat function, and engaging with you all, discussing cases with you all, without annoying Facebook ads and that kind of stuff.

So head over to www. protrusive. app if you’re not already on Protrusive Guidance, and I look forward to having a DM from you on there to say hello. Thanks for listening once again, I’ll catch you same time, same place next week. Bye for now.