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Decision Making for Anterior Composites – PDP211
Manage episode 462436043 series 2496673
How far should you extend composite resin?
When does edge bonding become a composite veneer?
How do you decide where to finish the restoration?
And most importantly, how do you avoid that dreaded yellow-brown stain line that can form on anterior resins?
These are just some of the burning questions tackled in this episode with my guest, Dr. Mahmoud Ibrahim. We dive deep into the artistry and engineering of decision-making in anterior composites.
Protrusive Dental Pearl: use a zirconia primer which contains 10-MDP (e.g. Monobond, Z-Prime Plus) on the intaglio of crowns to enhance bond strength, even with conventional cements like GIC. This low-risk, high-reward tip improves retention, especially for teeth with limited height. Incorporating a zirconia primer can significantly improve outcomes without switching to resin cement.
Interested in the Unchippable 2 Day Course? Click here to register your interest!
Key Takeaways:
- Choosing between edge bonding or veneers is not a black-and-white decision.
- The height of contour is key in cosmetic dentistry.
- Seamless transitions between composite and tooth are pivotal.
- Aesthetic considerations vary based on individual cases.
- Material choice is influenced by patient risk factors.
- Layering techniques enhance the natural appearance of teeth.
- Patient previews are essential for managing expectations.
- Thickness of composite affects durability and aesthetics.
- Understanding angles is key to successful restorations.
- Not all patients require the same approach to bonding.
Need to Read it? Check out the Full Episode Transcript below!
Highlights of this Episode:
- 02:43 Protrusive Dental Pearl
- 04:49 Personal Anecdotes and Health Goals
- 09:37 Anterior Composites: Edge Bonding vs Veneering
- 16:00 Importance of Finishing Composite Correctly
- 17:09 Understanding the Height of Contour
- 18:36 Importance of Layering in Dental Procedures
- 21:35 Choosing the Right Materials for Layering
- 23:56 Importance of Layering in Dental Procedures
- 27:14 Challenges and Solutions in Composite Layering
- 32:31 The Marshall Hanson Method
- 36:29 Mockups and Wax-Ups: Planning for Success
- 43:03 Treatment Considerations
This episode is eligible for 0.75 CE credits via the quiz on Protrusive Guidance.
This episode meets GDC Outcome C – Maintenance and development of your knowledge and skills within your field(s) of practice.
AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY (Direct restorations)
Aim: To enhance clinicians’ understanding and decision-making in anterior composite restorations, focusing on when edge bonding transitions to a veneer, optimizing aesthetics and functionality, and minimizing common challenges such as staining and occlusal complications.
Dentists will be able to –
- Understand the key factors that influence the transition between edge bonding to full veneers.
- Apply guidelines for minimum composite thickness and bonding angles to enhance durability and aesthetic outcomes.
- Identify high-risk patients and tailor material choices, layering techniques, and bonding approaches to individual needs.
If you loved this episode, make sure to watch Composite Veneers vs Edge Bonding – Biomimetic Dentistry with George The Dentist – PDP075
Click below for full episode transcript:
Jaz's Introduction: How far should you extend your composite resin up a tooth, i. e. like when is it just edge bonding and when is it a composite veneer? Is it somewhere in between? How do you decide where to finish that resin up a tooth? And then how do you avoid that horrible stain line that can sometimes form on your resins anteriorly?
Jaz’s Introduction:
So that horrible yellow brown line that you see around a composite. And when should you layer like different tints and shades? And when should you stick to monoshade? Just one shade. I’m a one shade one, the kind of guy, right? When is it okay to do one shade? When should you be layering? And related to that question is when can you do free hand and when do you need a wax up to be able to deliver the right result?
And something me, my guest Mahmoud Ibrahim also discussed is how the occlusal risk of a patient will also significantly impact what you should and shouldn’t do with your anterior aesthetics. And if you stick with us all the way to the end, Mahmoud will teach you about the minimum thickness, both on the incisal edge and labially, for optimal strength and aesthetics, and what angle should the composite be coming out of the edge.
So if you imagine the edge of a tooth and the angle on which the composite is bonded onto the tooth, there’s a specific angle that you should follow ideally. So you don’t mess up the patient’s occlusion.
Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Those of you who listening while you’re jogging or you’re on a train or you’re commuting, driving to work. Thanks so much for joining in. Hope you enjoy the show and those of you who are watching on either Procrucive Guidance app or YouTube or MedTube, you will notice that I’m looking a bit different. Well, I am sitting down, right? I’m usually standing for the last six years I’ve been standing and maybe I’m getting old.
But you know, I’ve decided now to take a seat, right? I usually feel like I have more energy when I’m standing up, but I want to do more episodes this year than ever before. I want to make more content this year than ever before for you guys. So I’m just looking at my body, right? Get used to me just sitting down a little bit more.
Hope that’s okay with you guys. And before we dive into this episode with Dr. Mahmoud Ibrahim, a very welcome guest, as always been on several episodes before and is my co presenter on the occlusion course. His composites are just out of this world. Like just check out his Instagram. He is a true artist and I’ve been encouraging for a long time to do more on composites.
So he’s going to branch into that a little bit more this year and I thought it’d be nice to tackle an episode about decision making. I want to tap into Mahmoud’s mind. How does he decide when’s it edge bonding, when’s it veneer, and the overall decision making, treatment planning guidelines he follows for his anterior composites. This episode is eligible for CE. We are a PACE approved education provider, and you’ll be able to do that by answering a few questions at the end if you’re on the Protrusive Guidance app.
Dental Pearl
Every PDP episode, I give you a Protrusive Dental Pearl, and this pearl is related to an article I published on the app about top tips on bonding to zirconia.
You see, in 2017, I asked Dr Nasser Barghi at the STA convention Singapore. He’s a big shot in ceramics, right? And I said to him, look, now that zirconia is getting so good to bond with, should we now move away from lithium disilicate onlays and overlays, and should we move towards zirconia? And 2017, he said, listen, zirconia bonding is really good now, but why move away from this wonderful material, lithium disilicate?
I asked the same thing seven years later, so recently at the BACD conference, I asked the same thing to one of my idols, Dr. Chris Orr, and he said the exact same thing. He said, yes, you can bond to zirconia in this strict protocols. But why? When we can do beautiful partial coverage restorations posteriorly that have enough strength and bond just so predictably in lithium disilicate.
So just some food for thought there. I know some of us are doing zirconia onlays and overlays that’s fine, go for it. But I have yet to found a reason to deviate away from lithium disilicate. Well, I’m using the adhesive approach. Now, of course, for resin bonded bridges, I’m using zirconia as well as metal and for my vertical preparations. I am cementing zirconia crowns.
But the top tip I want to give you from that article I wrote summarizing what I’ve learned of the years about bonding to zirconia one top tip is even if you are cementing by using a zirconia primer for example monobond or z prime plus or clear fill ceramic primer something that contains that 10 MDP.
If you use it on the intaglio of the crown, even if you’re not using a adhesive cement afterwards, even if you’re not using resin cement to actually bond your zirconia by using the primer, the zirconia primer, you are actually improving your bond strengths, even with the GIC that you’ll use, for example.
So this is really useful. This is like low risk, high reward. If you have a tooth and you’re crowning it and maybe it’s got less height and you’re thinking is that retention form going to be enough, then perhaps you could still use your conventional cement system, but by using the zirconia primer, you actually get a better outcome. So that’s a top tip I want to pass on to you. Now let’s join this episode on decision making on anterior composites.
Main Episode:
Dr Mahmoud Ibrahim, my brother from another mother, welcome back yet again to Protrusive Dental Podcast. How are you, my friend? Other than sniffly.
[Mahmoud]
Oh, sniffly and coffee and I apologize everybody if I sound like a frog, but yeah, it’s always great to be back talking about a topic I absolutely love. Yeah. So thanks for having me again. How are you, Jaz?
[Jaz]
I’m okay, buddy. I’m okay. I’ve just, you know, on Christmas Day, I hosted my sister and my brother in law and their family and stuff. I had my nephew over, that kind of stuff. It was quite nice. And I did this thing where I went around, only because I really wanted to hear what my son, Ishaan, was going to say to this answer. I just went like, did like a question time with everyone. So I asked everyone like, what was your best moment of the year, right?
[Mahmoud]
People must dread having you over for parties, right?
[Jaz]
I know, I’m like a terrible host. Well, I was the host. I was a host, so I asked him, what was the best moment of your year? Okay. Well, what’s your song of 2024 and what’s one thing that you’re going to change about yourself in 2025? And so before you answer, I’ll say mine just gives you a bit, buys you a bit of time to think of yours. I’ll say mine. Okay. So my favorite song was Hass Hass by Sia and Diljit Dosanjh. So like a Punjabi, but like with Sia.
So it was a nice little remix, which was good. My best moment was probably our family holiday went to Doha. It was. Just holiday, basically. My wife’s was actually our holiday in Tenerife, but that was a different one. So holidays, for us, is a big thing, obviously, so it’s really important. And then, the thing I’m gonna change about myself next year is based on this recent I don’t know if you saw my story recently, right?
That I do my regular blood tests as inspired by Prav Solanki, and my HPA1C, my diabetic marker, just crept up a tiny bit, because I’ve got, like, so many tests worth of data. The cool thing they can do is they can test, they can see the trend and plot the graph, and just a tiny little blip! like a slight increase, right?
So usually for most people, this is insignificant. Like if it was my first test, I’d be like, yeah, yeah, good. But only because they know it’s the trend going up. Did the GP in his report say, hey, mate, you gotta just be careful diet, exercise, that kind of stuff. I felt so bad. And you know what it is?
It’s all that snacking in the staff room that we are the worst, right? All the snacking. So I made a vow to just be a little bit more careful with my diet. Like everyone, my dad’s side of the family is diabetic. So, shout out to Tom Levine, who messaged me a book recommendation on the back of that. He recommended the book, Metabolic, I believe it is by Dr. Lustig. So, just downloaded that on Audible, so I’ll let you guys know next month how it is. But Mahmoud, back to you now, buddy, okay? So, favorite song of 2024. Doesn’t have to be a 2024 song, by the way. It can be a song that represents 2024.
[Mahmoud]
So, a lot of the time, I think I mentioned this song to you before, but Remember the Name by Fort Minor. Okay. That’s a little bit of a hype song. It’s an old song though, so maybe a lot of your listeners might be like, what? Go look it up. Advisory, like, don’t listen to it in front of kids.
[Jaz]
Link in the show notes.
[Mahmoud]
What would I change for 2025? It’s definitely health related though as well. Unfortunately, I don’t need blood markers to tell me that I’m not taking care of myself. I know I’m not taking care of myself. You know, again, it’s just been such a busy, busy year for both of us. I think next year is not going to be any less busy, but I think I just need to get a little bit better at organizing myself and prioritizing certain things. We had a house move, etc. Things are starting to settle back down a little bit now, so I’m going to try and allocate a certain amount of time to just look after myself. Exercise. Eat better and all that sort of stuff.
[Jaz]
I don’t know how you’re recording me right now. You’ve got three kids. I’m two. Now I’m looking like I’m in my little back room. I’m looking across. I see havoc, forks flying in the air. Like I’m seeing it all like from there. I’m just pretending like I’m just recording.
I’m just working right now. But I don’t know how you do it, man. So more power to you. Just amazing what you achieved with three little ones. And so the next question we’ll say, what are you going to improve? And then the highlight moment of 2024. I know it’s been a year with lots of ups and downs and I don’t go into personal stuff and I’m here with you all the way, my friend. Just to remember the positive. Remember the good. What was your favorite moment?
[Mahmoud]
I mean, if I want to do workers, I’ll split it up. Yeah. I’ll split it up into sort of more worky stuff and more personal stuff in terms of best moments. I think probably one of the most fun moments was us in Chicago. I think that was this year, you know, believe it or not.
[Jaz]
Crazy.
[Mahmoud]
It feels like it was a long, long time ago. It was actually this year.
[Jaz]
Like professionally. Yeah. That was also the top moment for me professionally as well. I go with you to meet all our heroes, shaking hands with the Spear, not washing her hand and then shaking her hand with John Kois so that they actually shook hands in a funny kind of way. It was amazing.
[Mahmoud]
He didn’t go to the toilet in between. In terms of personal, it’s not necessarily a specific moment, but over the past like month or two, I’ve actually seen quite a change in the maturity of my older son. Like he’s 11. I actually, at one point I stopped and I looked at him and said, I think you’re getting it.
And by that I meant you’re getting what it means to become a little bit more mature, to become the older brother that your little brother and your little sister need and that your parents need. That was a lovely moment for me. And I think he really felt like really proud that we noticed.
[Jaz]
Cometh. Cometh man.
[Mahmoud]
Personal though. Yeah, yeah, yeah, yeah. That was nice.
[Jaz]
Very nice. Well, about half the Protruserati are like skip, skip, skip, skip, skip. Get to the good big comes big the other half like, you know what? We love this stuff, right? So whatever guys, if you love it, then we love you too. If you don’t love it, I still love you.
Go to the clinical bit, which is now, right? Because right now, Mahmoud, we are discussing a very hot topic. It was always a hot topic. It’s been a hot topic for about 8, 10 years now. Last time I recorded this similar topic was with George Cheetham. Took away so many nuggets. So I had a great time discussing with George, aka George the Dentist, on composite and edge bonding versus veneers, that kind of stuff.
That was really fun. I really enjoyed that. The main thing I took away from that episode, the main lesson I took away, which I just want to echo, is when you are doing bonding with your patient, That initial appointment, obviously so, so important gauging expectations, seeing what’s within your skill set, but just telling them that, okay, if you want to do this dance and we do this together, then the maintenance side of it, let’s have an annual appointment, right?
Kind of like when you have your car serviced every year, right? It’s like a commitment that you talk about right at the beginning. Okay. And you attach a fee to it. Cause I remember back in the day, like, okay, yeah, you need polishing and rebuffing of your composites now and again in the future.
And it’s just like a sentence that you say, but when you actually say, okay, it’s an annual appointment, X fee, and this is your maintenance. If there’s anything chipped or any issues, we will take care of it. We will make them look good. And we’ll also do your examination at the same time, kind of thing.
That was a really nice takeaway from that episode for me. But I just want to build on that because I see your work, Mahmoud. It’s phenomenal, right? Absolutely phenomenal. The resin artistry. You’re a multi award winner now. I know you hate that term. I hate it as well, but whatever. You are, it is what it is, right?
And your work speaks for itself. So I am happy and excited to just extract your mindset when you’re doing this kind of work. And obviously we did the BACD workshop together, British Academy of Cosmetic Dentistry. We did the unchippable workshop. Okay.
You were the workhorse in terms of the beautiful workthat you provided, the demonstrations you did, and you’ve had so many great questions from the delegates. So I’m just going to like go through some of those questions, which are so, so key, right? I guess we have to start with is the decision making process. You have a case in front of you, and it’s quite difficult without a specific case, but just an overarching decision making kind of like flowchart of when would you go for edge bonding?
And just to clarify, I remember doing this and someone on YouTube commented, what is edge bonding? Because in different countries, it may mean different things. It literally is adding some composite to the incisal edge of a tooth, everyone. Edge bonding. Whereas resin veneering is when you take it up the labial of a tooth a bit more. So Mahmoud, what principles can you share with us in terms of decision making and which to do when?
[Mahmoud]
Hmm, yeah, so, I mean, I want to first start by saying George Cheetham’s point is incredibly important, kudos to him, his work’s phenomenal, big shoes to fill, love to get it.
[Jaz]
Sending you love, George.
[Mahmoud]
And I use the phrase to the patient. I say, you need to budget financially and sort of mentally for the maintenance of these, right? Because not only is paying for the maintenance annoying, but also having to attend appointments can be annoying.
[Jaz]
This is just like car servicing. It is literally just like car servicing. I hate taking my car for service. Half a day out of your life gone.
[Mahmoud]
Yeah. Luckily, we don’t get a lot of them, and it’s all the principles that we might discuss today. But I also want to say that edge bonding and veneering, it is not a black or white. It is not one or two. There is no dividing line.
And this really is the beauty of resin. There is a whole spectrum in between from covering just the insides of the edge to doing a full veneer that I do. And I might do three, if I’m doing six teeth on a patient, two teeth might end up here, two teeth might end up here, two teeth might end up here.
[Jaz]
Like a spectrum, like a gradient, right? So some is pretty much on the edge, whereas others edge, and maybe covering up the labial by a couple of millimeters. And the other one might be going shy of the gingiva just by a couple of millimeters. That’s what you’re trying to say, right?
[Mahmoud]
Yes. Yes, exactly. There are certain things I try and avoid. Nobody wants huge, chunky, massively thick composites, whether that is, it’s too thick on the incisal edge or whether it’s around the cervical margin and you’re getting, cause that’ll black trap plaque, it’ll get stained and then you don’t look very good.
So obviously my preference is, treat the case if alignment is needed, do the alignment first and do try and minimize the amount of composite I’m going to apply to the teeth. However, the word minimal seems to always, it’s become cool now to try and put the least amount of composite possible on this tooth to affect some sort of change.
And for me, I prefer to use the term appropriate. It’s the amount of composite that I need to use that will give the patient what they want. So the patient might come in saying I want composite veneer. But actually what you need to dig down into is what is the look they want and then that will help you decide how much composite you need to use and that sort of appropriate amount of composite rather than minimal.
Because I’ll give you a little bit of, just a tiny bit of food for thought here. Just a random example. Imagine you’re doing some edge bonding, yeah? And you’ve covered the edge of the tooth by like a millimetre. Okay, and that’s it. That’s real minimal.
[Jaz]
So purely on the incisal edge?
[Mahmoud]
Purely on the incisal edge, just about a millimetre up the incisal edge. And now, you’re very happy with yourself. You’ve put on a very, very small amount of composite, and it looks good. Now, none of us are perfect. What happens if you get a little bit of staining underneath that margin? Now you go in and you try and polish it away. Now you’ve got very little room to play with, right?
There’s very little composite covering the surface of the tooth that you can polish away. And end up with an invisible margin, still, and a blend that is good. You just haven’t left yourself very much space. If that composite was maybe two millimeters up, feathered down to super thin, and it does stain, you’ve just got a little bit more room to play with. Okay?
[Jaz]
To still I remove the stain, but also to still have enough of a blending zone, a blending transition.
[Mahmoud]
Yes, yes. And I’m not saying I cover the full face of every single tooth because I don’t. I almost never take the composite actual actually to the gingival margin. Okay. Almost never. Because that area is just critical in terms of hygiene, et cetera. So I almost never do that, but there are certain aspects that I sort of consider when I’m trying to decide where on the tooth I’m going to stop it.
[Jaz]
Is there a no man’s zone? Is there a no man’s land? Like, when you’re we’re playing tennis, right? We’re playing tennis, right? You’re either by the net or you’re at the back. You don’t want to be caught in no man’s land because like it’s really difficult to play shot. Did you know that? Did you know that about tennis?
[Mahmoud]
I’ve heard about it. Yeah, I don’t play tennis.
[Jaz]
I know you’re talking. I know you’ve shown some images before. I love this term, right? And maybe if you want to screen share this, for those of you who are more visual here, the chasm of crap. It’s a great time. Chasm. Okay, fine. There we are. See, English is my second language, alright? So, go with me. Third language. Okay, fine. The chasm. Are you sure it’s chasm? Because I like the word chasm.
[Mahmoud]
It’s a chasm, dude. A hundred percent it’s a chasm.
[Jaz]
I don’t know what that is. I don’t know what a chasm is. So, there we are. What is a chasm?
[Mahmoud]
Like a valley. Like a-
[Jaz]
The Valley of Doom, the Chasm of Crap, which is cool because it has more alliteration, I like it. So, the Chasm of Crap, as Mahmoud once so brilliantly illustrated, is like, if you finish your composite like in a random place on the labial surface, then you get this like little con cavity, whereby it just collects stain.
Can you share your screen or not? Have you got that image to share? Tell us about this chasm of crap and this area where you get like this mid facial stain. How can you prevent that? And is that a guideline that you use in terms of where to finish the resin?
[Mahmoud]
Yeah, a hundred percent. So what I don’t want people to do is have the composite on the edge of the tooth, sort of meet the tooth in like a depression, right? So my guide as to where to end the composite usually is the height of contour of the tooth. Why? Because that allows a smooth, smooth blend. If you end below the height of contour of the tooth. What happens is you get the thickness of the composite and then it dips down into the tooth and then the tooth starts again and you have this like, little V shaped depression between the two.
A, it’s impossible to polish. Like, you’re polishing it, polishing, polishing it and you end up with like, this white line. But also, it’s impossible for stain not to get caught in there because the patient can’t brush it very well. That’s why I call it the chasm of crap because you always end up with like pasta sauce and stuff after they’ve eaten.
[Jaz]
Just for the students and the young dentists who are maybe new to the term height of contour, it’s kind of like the maximum bulbosity in like the gingival third often area, just slightly maybe more incisive than that. And it’s kind of like a good reference point whereby you can put your probe and then, I’m just trying to visualize how to explain this concept to someone who, because we get this question sometimes in the podcast, how do I identify the height of contour? Any guidelines you can give. So like using an occlusal mirror maybe.
[Mahmoud]
Yeah in a way I mean, okay, so this is why this really does need to be done on a course. But it’s the height of contour relative to the composite. So if you imagine your final facial surface of the composite and whatever angle that is at. What I want that composite to do is to then meet the tooth, and then the surface of the tooth continues that same trajectory as the face of my composite, right?
So, that’s how I want you to think about it. Because the position of that height of contour is going to depend on the inclination of the tooth, going to depend on the shape of the facial surface of the tooth, and it’s also going to depend on the angle of your composite, right? If your composite is, really flat up and down, really quite thick at the incisal edge, then the height of contour it’s going to meet is going to be up by the cervical area, right?
If your composite is quite thin, rolled inwards incisally, which is something we’ll talk about as well, right, then its trajectory is a little bit more out to the facial. It’s going to meet a height of contour maybe slightly earlier, right? If the tooth has that incisal curve naturally.
[Jaz]
I think the most important thing to grasp here is that as you take a probe and you take it from the enamel to the resin, it should be seamless. There should be no catch. There should be no depression. There should be no chasm of crap where we’re staying, we’ll do. But the other thing to not do the opposite is don’t just have like a tooth and then edge bonding, like just composite completely glued the edge of the tooth. But you have a great visual for this, which obviously for the purpose of the podcast, which shouldn’t describe, describe the issue there. In terms of having composite just glued to the edge of the tooth.
[Mahmoud]
So the problem there is mostly optical in nature. You’re asking two completely different materials to behave optically similar in order to fool the eye so that the person looking at this tooth doesn’t see a join between the composite and the tooth, right?
But you’re going from an area where the composite is that is sort of 100% composite thickness, 0% tooth thickness, and to immediately go on to an area that is 0% composite and 100% tooth thickness. And those two things cannot act optically the same very easily. It’s better that you have a gradual change.
So you go from an area that is completely composite which is basically the edge of the tooth that you’re adding to, right? And that ratio of tooth to composite gradually changes as the composite lips over some of the tooth structure so that when the light hits it, it’s going through a little bit of composite and then a little bit of tooth.
And that ratio will gradually changes from a lot of composite towards the incisal edge and less tooth to more tooth and less composite as you go further up the tooth, depending on how much composite sort of you lip over the edge.
[Jaz]
So you’re right. You don’t want to go from like composite to tooth in a harsh way. It needs to be composite to a bit of composite bit of tooth to then tooth only. But that needs to be like a nice seamless blend. And I think there’s so much in the whole episode, two episodes, we can talk about characteristics and techniques and top tips to get like an invisible blend and stuff. And we could talk about days for that, but just more on the decision.
[Mahmoud]
We literally do on the course.
[Jaz]
But in terms of edge bonding and resin veneers, you’ve kind of made it quite clear that it’s a spectrum, right? When you’re doing a resin, you’re deciding case by case, and it can finish anywhere on the tooth, depending on that specific case. But then there are-
[Mahmoud]
I want to split it up a little bit. And to like, just to summarize, you’ve got your aesthetic reasons, but we also cover things like, your unchippability reasons, right? The reasons for strength or longevity. Aesthetic reasons to cover more of the tooth, obviously if you’re changing the color, but slightly less obvious ones if you’re changing the texture of the tooth.
So if the patient’s enamel has natural like pits and stuff and they want to get rid of that. Sometimes the tooth has sort of banding that you can’t get rid of with whitening or icon. But one that might not be so obvious is I do tend to change the shape or even the apparent shape of a tooth a lot by changing the position of the line angles.
Now, I can’t do that if I don’t extend the composite up the facial of the tooth a little bit more. So those are just a few of the considerations I’ll make, especially if you have fairly triangular teeth and you’re trying to change them, you have to cover a bit more of the tooth. And then when we talk about longevity, that’s when we start talking about composite thickness, angles, and things like that, which we’ll get into.
[Jaz]
I think when we’re talking about edge bonding, let’s composite again, and we talked about, yes, this spectrum is in between zone, but there is something that is more of edge bonding, there’s more of a resonating.
And like you said, sometimes you do the other mode down for color change, for example, more major shape change playing about with the line angles. When we’re doing that kind of work and that distinction in a way, are you using different materials? Do you think that, okay, because you’re doing more of an edge bonding, you’re going to use a certain type of composite, or because you’re doing more of a resin veneering, or you’re trying to achieve a different objective to do with either shape or color, are you changing the composite that you’re picking up?
[Mahmoud]
Not necessarily for whether it’s edge bonding or the composite video. So there are certain decisions that I make or survivability reasons. So I’ll give you one example that’s not to do with the type of material. But for example, I don’t charge differently, right? I don’t charge. I don’t have two separate charges for composite edge bonding and it comes with a veneer. Okay, I do get patients ask how much is this versus this. It sounds exactly the same.
[Jaz]
It’s a per tooth fee.
[Mahmoud]
It’s a per tooth fee because I want to be free to do what I need to do again to give the patient what they want. So that’s one. Second, the choice of material tends to be based on, so we tend to categorize our patients into a HORP or a LORP. So for those who don’t know, a HORP is a high occlusal risk patient. So it might be a patient that has huge masseter muscles, a patient who we can tell maybe grinds their teeth.
They’ve got attrition, tooth to tooth rubbing, right? That is a high occlusal risk patient versus a LORP or a low occlusal risk patient. The patients have still lovely mamelons on their teeth. You can see all the insides of halos and stuff. They don’t grind their teeth. Their muscles are quiet or not hypertrophic.
So if I am dealing with a patient who I consider to be a HORP, I will almost always default to using a material that is more chip resistant, more so stronger in the sort of areas that receive a lot of load for me personally, I prefer to Venus by Kulzer. That’s what I use. If the patient is more of a LORP and I am aiming for more intricate sort of layering, I’m going to have some fairly weak materials at the edge anyway, because of the tints and things like that, then I might still use Venus as my palatal backing.
To gain a little bit of strength, but then for my layering and stuff and tints, I’ll use either Cosmedent’s Renamel. I use Filtek Supreme XTE and I use Tokuyama Estilite. Those are sort of my three go to that I sort of mix and match.
[Jaz]
So a nice distinction there, high occlusal risk versus low occlusal risk. And that’s important for decision making, unchippability as we like to call it. Next question then is in terms of getting a good result, how important do you think is it for our colleagues to be thinking about layering, right? Because me, I’m a one shade wonder. You know that, right? I’m always a one shade.
All my cases I show, the course stuff, online, I’m just like, hey, I’m going to use one shade and I’m going to do the best I can with that one shade. Like, as I often joke, but it’s kind of true, is my speciality is getting someone from a 4 out of 10 to like a 7 and a half out of 10. You are there taking 7s and turning them into like 10s, right?
So that’s the difference between me and you. But how much of that do you think is due to layering? I’ve never actually asked you, what percentage of your cases are layered versus just one shade wonder.
[Mahmoud]
So I think if you want to make teeth look more natural, like with your incisal effects, it really comes down to two things mainly. Okay. How are you going to cover the transition between the tooth and the composite? And do you want to add incisal effects or not? Those are probably the two biggest decisions you need to think about in terms of whether you’re going to layer or not. If you don’t want to layer, you want to use a single shade, then you’re not going to be able to add incisal effects, so forget that.
So if it’s a patient who wants that, you’re not going to be able to give it to them. Do patients ask for that? Not really. I tend to get patients who ask for that, but I think that’s because that’s the work I put out. But in general, patients don’t tend to care. But it’s then about how you’re going to cover the transition between the tooth and the material, okay?
If you don’t have enough thickness of composite, the composite might be a bit too translucent and you’ll see that grey line, you’ll see the transition between the tooth and the composite, in which case you might need to resort to a lot of beveling of the tooth, create thicker bit of composite at that graduation where it changes from mostly tooth to mostly composite. That’s where you need to maybe heavily bevel.
Interjection:
Hey guys, just Jaz interfering here. I hope you’re enjoying protrusive content. Hope you enjoyed all the content throughout the years, and there’s so much to come. Now, if this year you’re wanting to learn how to do Vertical Preparation, as you know, I’m a huge fan of Verti Preps, as you call them.
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[Jaz]
See, remember, with my older patient base, they’ve already got like, worn teeth and chipped teeth and jagged edges, so for me, that’s very easy to do, hence why I get away with it, I get a good blend, because again, I make that shape, and I am able to bevel and add my one shade, which is gonna be good enough for that patient in my population, based on the village that I work in, but for your patients, yeah, they’re younger.
I’ve seen them. They’re younger and the kind of work you put out and they’re trying to small transformation to do. They are the more cosmetically focused patient. And so I see what you mean in terms of even if you’re going to use one shade, you are perhaps not in a position to bevel or bevel aggressively because of the fact that you are dealing with quite nice enamel already. You don’t have to scratch it. Is that your thought process in that scenario?
[Mahmoud]
Yeah, but it’s also even more. It’s even trickier in that sometimes, because if the tooth is intact and you still have the incisal one to two millimeters, it’ll have the halo, which tends to look quite opaque, and then you have the band of translucency in the incisal edge.
And what’ll happen is if you put a thin bit of composite on there, you’ll actually still see those things through, and it’ll look really weird, because you’ll have a really thick band at the bottom now, where your composite is, and it might blend okay onto the halo, but then you’ll have like this gray bit in the middle, right, which looks really, really weird. So my preference, and I call this sort of transporting the incisal edge, yeah, is I use opaquers in the area of that. So the natural translucency of the tooth.
[Jaz]
And it is like flowable?
[Mahmoud]
Yeah, flowable opaquer is because they can be very, very thin.
[Mahmoud]
That is a white opaque, if you like, but then you can get opaquers that are either vita shaded, so the ones that I like to use, or they’re shaded as A1, B1, A2, whatever.
[Jaz]
Or would they be A01, for example, over opaque that? Is that kind of how they term it?
[Mahmoud]
These aren’t named like that, but I guess different brands can call them different things, right? I don’t know. So the ones I use are the Cosmedent ones, and I’m not sure that anybody else makes vita shaded liquid opaquer. I might be wrong. Someone correct me if they know otherwise. Those are the ones I use because they are vita shaded. So they’re not bright white. They will match the vita shade as close as possible.
[Jaz]
The shade that you use here, for example, let’s say you’re going to create, you’ve done some teeth whitening, okay, because patients want to have white teeth if possible, and then you’re going to go for a bleach shade or BXL, whatever, that’s usually a modal thing. I don’t know how often you do that.
It’d be nice to know. So, does that mean that the opaque- Okay, I thought so. Phew. Does that mean that the opaque you’re going to use is going to be the same shade as the shade you’re aiming for, or you’re trying to go halfway between to try and create a blend or transition? What’s the thought process in terms of the shade that you use?
[Mahmoud]
No, if I’m aiming for a bleached shade tooth, then I’ll use the A1B1LO, it’s called, by Cosmedent, and so it covers everything from A1 to LO. What I would use for teeth that have been bleached, okay, they have a B0, which is even lighter. But I very, very rarely use that one because it’s like an internal shade that I’m trying to sort of mimic the dentine, if you like.
I don’t really want it to be super bright and then shine through unless I’m trying to aim to give the tooth those like hypercalcifications or a brighter halo. I’ll use it there. But otherwise I stick to the A1B1LO in a lot of cases just to hide that grayness of the natural translucency of the incisal edge, cover that, and then I move it more incisally using then my gradient to mimic the new translucent band. Does that make sense?
[Jaz]
Yeah, yeah.
[Mahmoud]
So there’s no way I can do that if I’m doing a single shade.
[Jaz]
And so how often are you doing a one shade wonder, versus how often are you using tints and layering? So basically, how often do you get a HORP? How often do you get a LORP?
[Mahmoud]
I’m probably seeing a lot of lorps at the moment, because you tend to get a lot of people who want nicer looking smiles, but it’s mainly that they’ve got misalignment. You do the invisalign, you do the ortho. And then it’s just about tidying certain things up and the more we look at patients and the more we realize maybe the envelope, maybe it’s envelope issues, we talk a lot about restricted envelopes of function, your lack of overjet, et cetera.
And if that is what I think is making the patient a horp, right, once I’ve resolved that with my ortho, I’ve given them a little bit more overjet, I’ve undeepened the overbite, then I’m maybe a little bit more free to then layer and use the materials that I can get a nicer aesthetic result with. Whereas if it’s a patient who I can see clearly, is grinding their teeth, even maybe even during the Invisalign, you can see that the aligners are getting worn out and they’re cracking them.
Then no, I’m going to go single shade. I’m going to go with Venus, more than likely Venus pure at the moment. That’s like my favorite one. Yeah, I’d say that’s probably like 30% of my cases. If I put the pictures up side by side, could I choose an absolute personal sort of favorite way of doing it?
Me personally, like, obviously I love the layering aspect, the artistry of it, it’s just so rewarding and it’s so much fun to do. But a patient wouldn’t tell the difference, I don’t think. Unless it’s a blown up picture and they say, I want that, fine.
[Jaz]
Okay, well, in that scenario then, when you’re considering layering, do you always do it whereby you’re being like a 3D printer? You’re like, you’re making the palatal shell, you’re then adding this tint, that tint, that shade, it’s like a recipe book that you’re building, and you’re building a layer upon layer upon layer, and then the final enamel layer, and then polishing it back versus MHM, Marshall Hanson. That’s the Marshall Hanson method.
I see a lot of his stuff online. The cut back his technique. Basically you do the one shade like I would do. And then like the next day or the same day, I don’t know when you do it, like in 48 hours, whatever you cut it back. Like you would do an EMAX, right? And then you bake all your tins in. Okay. Have you ever done it that way?
[Mahmoud]
I have, I’ve done it. I’ve done it, but in the same appointment. So I’ve done cut back. So built the entire shape, get the shapes, right? I think the biggest benefits of it is what scares people from using tints or layering translucent masses and stuff is if they get them in the wrong place, whether it’s gingival incisally in the wrong place, or whether it’s buccallingually in the wrong place, then when you come to finish and polish it, it’s going to look like crap, right?
You’re either going to have too much translucency, too little translucency, you’ll get rid of your halo, or your halo would be too thick, or whatever. So the idea with that is if you get the shape perfect frame is perfect, then you can cut back and you know where you need to put your effect and they will look good.
So that’s mainly what they’re trying to avoid is getting the effects in the wrong place. I have a pet peeve. I think this is from my childhood, honestly, I love you mom, yeah, mother, I love you. But there is one thing you do. You’ve always done this and it pisses the hell out of me.
It’s like repeating stuff. I hate being told the same thing seven times, but I also hate having to repeat something I have already done. Whether it’s through my fault or, or not, I just don’t like it and I don’t like repeating myself. When I did the cut back thing, when I cut it back, layered everything in and then was doing my finishing and polishing, I was like, oh my God, I’ve already done this.
And now I have to do it again? And it was really, really annoying. So for me, I don’t like doing that particular method. It has huge advantages as well in terms of the technique he particularly uses in terms of making things stain resistant stuff. Phenomenal technique. I know someone who’s gone on his course in the US and brilliant guy.
For me, I prefer to just do it once and get to the end and hopefully be happy. How do I avoid the pitfall of getting things in the wrong place? Couple of things. A, I always make sure I assess everything from multiple directions. And honestly, people talk about looking at your composite work incisal view.
So take a mirror, put it sort of in the patient’s mouth and look at the teeth as if you’re staring up its incisal edge. That’s one thing, but you need to also look from the side and do the same thing. Hold the mirror on the buccal of the tooth next door and look at the buccal side of the tooth. You can see like if someone’s watching me work, my head is moving around all the time.
And hopefully, I’m going to be sharing some of those workflows in the next year or so. And you’re going to see how much my head moves and what I look at. And even when I’m layering like my final composite, I’m not always looking at the tooth dead on when I’m actually placing the composite. I’ll be looking at it from the side.
[Jaz]
The one that Nick’s saying the whole time, man.
[Mahmoud]
Yeah, I know, I’m wrecked. But I get the patience to move as well. That’s one. But also, try and perfect each step before you move on to the other one. So you’ll also see, for example, when I do build my palatal shells, whether I’m doing it freehand, whether I’m doing it from a mock up or wax up, whatever, I will then adjust the edge of that palatal shell so that it’s the correct length, it’s the correct width, before I move on to the next step.
Because if you don’t, that could alter where your proximal wall might end up going, right? If you leave the incisal edge too broad, you might move your proximal wall back. So if the edge is too long and you haven’t cut it back, then you might put your halo on and it’s in the wrong place. Right? So I just make sure that each step is corrected.
I’ll take a disc, I’ll correct it, then blow the powder off with some air and then I just get some modeling resin on a brush and I’ll just wipe away any of the remaining powder and I can just carry on with my layering. But that’s how I make sure that where my halo ends up is where I want it to be.
[Jaz]
Because the last thing you want to do is put all this extra work, we’ve all done it. And then you just get away and then what’s the point of creating all that incisal halo and transducency if you’ve just adjusted it away. And that was one of the questions I was gonna ask you actually, is that when you’re doing layer by layer and you’re trying to get things right and then you’re cutting back and you’re adjusting, how do you get rid of that dust?
Well, we’ve answered it, air and then modeling resin. And so the other thing which this naturally leads to then is because you’re doing all the layering, right? And 70% of the case, you’re doing layering. Does that mean that in 70% of the cases you have a wax up? Because I do one shade, I can afford to do a lot more cases freehand, right?
What advice would you give to those listening about the need for a wax up? Because if you don’t know where your edge is going to be, if you don’t plan this, bake this in from the start, you’re going to get to a big mess, right? You can’t freehand a layering job.
[Mahmoud]
Agreed. So I would say my objective and however you want to get to it is up to you and I’ll give you some options. My objective is that I want that patient to have a preview of the expected lengths of the new teeth before I book them in for a really long appointment to treat them. How do I do it? I personally, most of the time I do a freehand mock up. So as you like to say, you’ll take your expired composite. Without no etch, no bond, I will mock up the new incisal edge length, the new incisal edge shapes.
You know, how big are the embrasures? I like fairly open embrasures. Some patients don’t, and I want to pick that up now, right? And I want to explain to them why the embrasures exist and why it’s important. And then once they have approved the mockup, so, I might need to adjust it. If they think it’s too long, I’ll shorten it.
If they think it’s too short, I’ll lengthen it. This is all done freehand. This is done no etch or bond. I can do whatever I want. Right? I can tell them, actually, no, I can’t make it that long because you’re going to chip it. Whatever.
[Jaz]
Are you doing just incisor palatal here? Like-
[Mahmoud]
Yeah, yeah. Most of the time. You could do full volume, but I don’t for a couple of reasons. A, it would take a long time. It’s a lot of composite. B, if I give that patient a mirror with this mock up, yeah? Which is like literally just palatal shells. And they go, oh, I love it. You know, I can’t wait. So excited to get my new smile.
And they’re all like giddy and stuff. I’m going to take selfies. I know that when I do the actual layering and it’s not half of a tooth. They’re gonna be over the moon, right? If they start going, oh, but it’s like, you know, and they shove the mirror like here and they get their microscope out, then I’m thinking, okay, this is gonna be a little bit, just book a little bit longer.
Maybe things might get a little bit more filling right? Just gives you a little bit of an insight into the patient, but it’s also a lot quicker. Like, I wanna be done with this mockup in like 15 minutes. I don’t wanna be there for an hour shaping everything. If I have a reason to think I need to, like if it’s a diastema closure case, right?
And I’m figuring out where am I gonna add the width, right? Because sometimes I’ll give a little bit of width to the centrals, a little bit to the laterals, a little bit to the canines, maybe sometimes you’ll give the laterals a little more, whatever, right? Then obviously you need to build up your proximal walls, because I really want to get a good idea of what the proportions are going to be. Harder to do that by just adding to the incisal edge.
[Jaz]
Case by case, but you could do a lot with incisor palatal, as you said, and it’s a great tip about gauging expectations. I actually love that so much. So, I mean, that helps to answer. And so really you’re using that as your wax up, you’re taking a putty of that, and then you’re using that in the future.
But how often are you doing, you actually using, because I know you’re doing wax up. How often are you getting the wax heater out and doing wax? And do you ever use the lab for either a digital or a traditional wax up?
[Mahmoud]
Yeah. So I will use a lab for either digital or traditional wax up if I don’t think I will have time to do it myself. So over the past 12 months, for example, we had an absolute ton on and I knew that every minute I had, I had to put into the content, the lectures, blah, blah, blah. So I did get a lot of self lab made stuff because I’ve kind of been there and I’ve done that. And I’ve learned a lot from doing the mix ups.
Now anyone’s listening hasn’t done their own wax up, man. Please, please. I beg you just do one. Do one, even if you do one tooth, you will learn so much about tooth shape. If you get the models articulating stuff, you can learn so much about occlusion. It’s hugely mind, eye opening, but yeah, I’ll get the lab to do it.
If I don’t think I have a lot of time and one tip I do, I can give sometimes is what I’ll do is I’ll collect my data up front. So I’ll do my photos. You do your x rays, you do all that sort of stuff. You’ll do your smile design and I’ll do a mock up of maybe one or two teeth. Intraorally.
That’s it. Okay. And then what that will set is because I’ll do the centrals. For example, that’ll set my incisal edge position. Which also sets the incisal plane, because you’ve got two teeth, they’re horizontal. Now the lab know that has to be the horizontal of the smile, and the incisal edge length.
And they’ll know where the midline is, because I’ll either put it using my embrasure, or it’s already there. And I’ll take a scan of that, as well as the scan of the upper and lower teeth without those things. So flick them off, and take normal scans. Those will go to the lab. The lab will make me my whitening trays. And they will send me back a wax up.
[Jaz]
So it’s like, I’ve kind of done a little bit of the work with the direct composite mock up technique, but then you get in the lab to do the rest with the either digital or traditional wax, right?
[Mahmoud]
Exactly. They’ve got those two teeth. Once you’ve got the incisal edge position and the photos, they can then digitally design everything else. Now, do you need facebow? Do you need fully mounted on a physical articulator to do these things? Now, if this patient is a lorp, and I’m not super worried about occlusal risk, and the lab have the incisal edge position from what I’m giving them and they’re just going to fill in the blank, then no, I don’t think you do.
I’ll just get the wax up back. And like I said, my objective is I need this patient to have a preview of their new smile before they say yes. I don’t care how you do it. This method, I will take putty index of the wax up and I’ll use some temporary crown bridge material. So my preference, luxa temp, and I’ll do a mock up on the patient’s teeth.
So no etch no bond. You fill the putty stent with your lux attempt, seat it over the teeth, let it fully set, take the putty off, and then they can have a look at the new lengths, just the new aesthetics in general. You can have a look as well. And most importantly, you can see whether you like it or not.
Did they actually match the incisal edge position? Is the midline straight? Is the smile canted or not? And if everything’s okay, and guess what, you’re fine. You can go ahead. And the beauty of it, it’s all composite at the end of the day. So even if there is slight adjustment you need to do at the end, you can. Now, if the patient is a horp and I’m designing canine guidance, group function, transition to crossover, blah, blah, blah, all that sort of stuff, then yeah, obviously I’m going to put in a lot more effort.
Maybe you’ll get the models mounted and plan the case appropriately. So that’s what I do, but I want the patient to have a preview. 100%. Okay, that is non negotiable for me. So, some people do it where you can have like a video call with the patient and then they come in straight for treatment.
I have never done that. I will never do that. That just sounds like a headache. So they will get a preview. I’ll get a preview and I’ll either have a wax up from which I’ll take palatal putty stent or I’ll have my own mock up in which I’ll make a palatal putty stent. Very occasionally I’ll do the mock up and if I’m lazy, I can’t be bothered.
But it was like a really predictable mock up. Like I knew exactly where I was putting everything. Then again, they’ve seen it, they’ve approved it. I’ve taken photos and then I’ll just freehand it when I come to do it. But I kind of, again, I’ve already in my head, I know I’m adding a millimeter here, adding a millimeter and a half here or whatever, I know it.
[Jaz]
That comes with the skill and experience. I think that the main takeaway here is give the patient a preview. And it also is an opportunity to gauge their sort of expectation and beware the chasm of crap. The three things you take away from this episode. And also it’s chasm, not chasm. Thank you so much for giving so much for sharing so much of your secret source.
There’s so much we still have to discuss. We’ve got the Unchippable course also launching now as part of our family of education that we provide. Our jingle should have played, I think somewhere in the middle of this, which I’m hoping people got pumped about, but sorry, we’re just going to say something.
[Mahmoud]
Well, no, I was just going to say there’s two other considerations that make me think, make me decide between whether it’s going to be a veneer or whether it’s going to be purely edge bonding. And it also can impact how many teeth I then need to treat. And these are ones that people probably don’t think about.
Now that you’ve mentioned Unchippable, obviously we go into these a lot in detail into in Unchippable, but we are about, I want people to listen to this episode and really take something a way that will help them. And it is, you want your composite to have a minimum thickness, right? But you don’t want your composite to be super thin on the edge.
And if you think about it, wherever that incisal edge needs to be, and it needs to be, let’s say, a millimeter, a millimeter and a half thick, that then translates into where the facial of your composite it’s going to have to be right. And then that could dictate whether the composite ends up being a veneer or just an edge bond.
Now let’s say you’ve got teeth that are misaligned. You got one tooth that’s a little bit more buccal onto it a little bit more lingual and you need that edge thickness. Now one tooth might end up being veneer. One tooth might end up not being veneer because if you veneer both, they’re going to again still be different facial thicknesses.
And this is where obviously pre restorative alignment becomes really crucial. You want that minimum thickness. So think about how that’s going to affect the. facial position of your composite And the last thing we talk about, and again, this may be a little bit more complicated than a podcast episode can take, but it’s palatal angle of the composite.
And I want to make sure that that angle isn’t too upright or too, what we call steep, right? I want it to be shallow, as in it’s coming out that way, so down and out on the upper. I had a case in just yesterday. She had some porcelain veneers fitted about a year and a half ago. And she came in and I don’t know where she had them done, but one of the veneers was out already.
I looked at it and it is really odd shape. Put it on the tooth. And honestly the incisal two to three millimeters curled politely. So far the tooth looked like a talon. Yeah. It looked like that on all this bit down here was ceramic. Once again, just imagine how this lower tooth when the patient’s chewing and stuff, it’s far more likely to knock into that added length because it’s going in. So I’m going palatally.
[Jaz]
Which is natural to tooth have a feature and sometimes in certain genotypes it’s more, or phenotypes, it’s more pronounced than others, and you have that curvature, but when we’re doing restorative dentistry, we know to bake that into your restoration is a dangerous thing for the envelope function, for the envelope parafunction, for so many factors there, so yeah, I can see how that would lead to an issue.
[Mahmoud]
Yeah, because if it’s the patient’s own enamel, right, and they wear it and stuff, they will come to you and say, okay, my teeth are worn, could you fix them? But once it’s your restoration and it breaks your chips, now it’s your problem. So that for me is, I always try and maintain the existing palatal angle of the tooth or shallow it, try not to steepen it.
So again, that will have an impact on the facial thickness of the composite and therefore it’ll have an impact whether it ends up being edge bonding or full facial veneer. These are difficult concepts to explain and understand without visuals. But we do spend a lot of time on self and chippable talking about these two things, which I think are crucial.
They are probably the two biggest decisions that affect whether I do veneer or edgebond. And whether or not I might say to the patient, actually, no, I can’t do just your two centrals. Because I’m gonna have to build them out and then you’re gonna look goofy. So we do the other two.
[Jaz]
What I want to finish on is just to reassure everyone that, you know how they said, okay, the market is saturated. It’s too many composite courses out there. And we thought about it. Oh my God, there’s a gazillion composite course out there. But the reason why me and you had no hesitation to come out with this is because this is not a composite course. Cause you’ve been on way more than I have. Like so many, I’ve been on a fair few.
No one’s ever talked about the kind of things that we’re going to talk about in the sense of actually getting longevity. They talk about the beauty, they talk about form follows function to some degree in the form and the shapes and whatnot, but how to actually put that in to your patient’s mouth that has the hypertrophic muscles, that has the high risk features, that has got an advanced amount of wear, and how you might mitigate-
[Mahmoud]
Identifying the high risk features. That’s where it starts with, right? And then nobody talks about that on a composite course. And it’s about not treating the wrong patient with the wrong modality.
[Jaz]
Correct. But then also when you treat a high risk patient, the different recipe and the rule book, which actually goes against some aesthetic norms. But if you go on composite course that we’ve been on, for example, and then you follow that recipe and hawk two years later, you’re going to get that chip. You’re going to get that break. Hence why we called it a very bold name. I remember being sat next to a very nice man at the BACD dinner. And he said, we looked at your topic on Unchippable and we thought that is very, very difficult to teach.
It’s amazing. We love the name. But we thought that was very, very difficult to teach, but we’re very excited with the prototype at BACD went very well, got loads of content. I think we’re going to be a hybrid model. So give lots of people some online learning as much as possible at home before they come in, because this is the future of education, right?
So that they can do as much hands on as possible. And that’s kind of model we’ll follow. So Mahmoud thanks again for everything, my friend, for being on here, for sharing your secret sources right to the end moment, and I would encourage everyone to follow Mahmoud on Instagram. I’ll put his handle in the show notes. And of course we’ll catch you next time. Thanks, buddy.
[Mahmoud]
Thanks dude.
Jaz’s Outro:
Well there we have it guys. Thank you so much for listening all the way to the end. Hope you enjoyed that geeky discussion all about decision making in anterior composites. This episode is eligible for CE, so if you’re on the Protrusive Guidance app, scroll down, answer those questions, get 80% and Mari, our CPD queen, will email you a certificate.
Mari actually emails you a certificate and every quarter, she’ll email you again a summary of all your certificates and then annually will send you a review of all the certificates that you gained. So do check that out on the Protrusive Guidance app.
Now, really importantly, if you love what Mahmoud teaches and his resin artistry, then you want to get on the Unchippable course. This is the first course of its kind that tells you how to make these composites beautiful, but actually gets them to work in your patient’s occlusion. This is not an occlusion course, but this is not just an anterior layering course. It is a beautiful marriage of the two. So how to make your teeth look good and last a long time.
All about anterior dentistry. We’re thinking of doing a few locations throughout the UK this year, and maybe internationally in the future. But join the waitlist www.protrusive.co.uk/unchippable. I know what a wonderful name, right? That’s /unchippable. Join the waitlist. Enjoy the revolution of actually doing these anterior beautiful restorations but sleeping well at night knowing that they’re not going to chip.
We’re going to tell you all our secrets but the hands on element will wow you. We also have like an online course that you join before the course so that on the live course we can focus two days on hands on as much as possible. That’s protrusive.co.uk/unchippable to join the wait list.
Thank you once again for reaching all the end. I’ll catch you same time, same place next week. Bye for now.
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Manage episode 462436043 series 2496673
How far should you extend composite resin?
When does edge bonding become a composite veneer?
How do you decide where to finish the restoration?
And most importantly, how do you avoid that dreaded yellow-brown stain line that can form on anterior resins?
These are just some of the burning questions tackled in this episode with my guest, Dr. Mahmoud Ibrahim. We dive deep into the artistry and engineering of decision-making in anterior composites.
Protrusive Dental Pearl: use a zirconia primer which contains 10-MDP (e.g. Monobond, Z-Prime Plus) on the intaglio of crowns to enhance bond strength, even with conventional cements like GIC. This low-risk, high-reward tip improves retention, especially for teeth with limited height. Incorporating a zirconia primer can significantly improve outcomes without switching to resin cement.
Interested in the Unchippable 2 Day Course? Click here to register your interest!
Key Takeaways:
- Choosing between edge bonding or veneers is not a black-and-white decision.
- The height of contour is key in cosmetic dentistry.
- Seamless transitions between composite and tooth are pivotal.
- Aesthetic considerations vary based on individual cases.
- Material choice is influenced by patient risk factors.
- Layering techniques enhance the natural appearance of teeth.
- Patient previews are essential for managing expectations.
- Thickness of composite affects durability and aesthetics.
- Understanding angles is key to successful restorations.
- Not all patients require the same approach to bonding.
Need to Read it? Check out the Full Episode Transcript below!
Highlights of this Episode:
- 02:43 Protrusive Dental Pearl
- 04:49 Personal Anecdotes and Health Goals
- 09:37 Anterior Composites: Edge Bonding vs Veneering
- 16:00 Importance of Finishing Composite Correctly
- 17:09 Understanding the Height of Contour
- 18:36 Importance of Layering in Dental Procedures
- 21:35 Choosing the Right Materials for Layering
- 23:56 Importance of Layering in Dental Procedures
- 27:14 Challenges and Solutions in Composite Layering
- 32:31 The Marshall Hanson Method
- 36:29 Mockups and Wax-Ups: Planning for Success
- 43:03 Treatment Considerations
This episode is eligible for 0.75 CE credits via the quiz on Protrusive Guidance.
This episode meets GDC Outcome C – Maintenance and development of your knowledge and skills within your field(s) of practice.
AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY (Direct restorations)
Aim: To enhance clinicians’ understanding and decision-making in anterior composite restorations, focusing on when edge bonding transitions to a veneer, optimizing aesthetics and functionality, and minimizing common challenges such as staining and occlusal complications.
Dentists will be able to –
- Understand the key factors that influence the transition between edge bonding to full veneers.
- Apply guidelines for minimum composite thickness and bonding angles to enhance durability and aesthetic outcomes.
- Identify high-risk patients and tailor material choices, layering techniques, and bonding approaches to individual needs.
If you loved this episode, make sure to watch Composite Veneers vs Edge Bonding – Biomimetic Dentistry with George The Dentist – PDP075
Click below for full episode transcript:
Jaz's Introduction: How far should you extend your composite resin up a tooth, i. e. like when is it just edge bonding and when is it a composite veneer? Is it somewhere in between? How do you decide where to finish that resin up a tooth? And then how do you avoid that horrible stain line that can sometimes form on your resins anteriorly?
Jaz’s Introduction:
So that horrible yellow brown line that you see around a composite. And when should you layer like different tints and shades? And when should you stick to monoshade? Just one shade. I’m a one shade one, the kind of guy, right? When is it okay to do one shade? When should you be layering? And related to that question is when can you do free hand and when do you need a wax up to be able to deliver the right result?
And something me, my guest Mahmoud Ibrahim also discussed is how the occlusal risk of a patient will also significantly impact what you should and shouldn’t do with your anterior aesthetics. And if you stick with us all the way to the end, Mahmoud will teach you about the minimum thickness, both on the incisal edge and labially, for optimal strength and aesthetics, and what angle should the composite be coming out of the edge.
So if you imagine the edge of a tooth and the angle on which the composite is bonded onto the tooth, there’s a specific angle that you should follow ideally. So you don’t mess up the patient’s occlusion.
Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Those of you who listening while you’re jogging or you’re on a train or you’re commuting, driving to work. Thanks so much for joining in. Hope you enjoy the show and those of you who are watching on either Procrucive Guidance app or YouTube or MedTube, you will notice that I’m looking a bit different. Well, I am sitting down, right? I’m usually standing for the last six years I’ve been standing and maybe I’m getting old.
But you know, I’ve decided now to take a seat, right? I usually feel like I have more energy when I’m standing up, but I want to do more episodes this year than ever before. I want to make more content this year than ever before for you guys. So I’m just looking at my body, right? Get used to me just sitting down a little bit more.
Hope that’s okay with you guys. And before we dive into this episode with Dr. Mahmoud Ibrahim, a very welcome guest, as always been on several episodes before and is my co presenter on the occlusion course. His composites are just out of this world. Like just check out his Instagram. He is a true artist and I’ve been encouraging for a long time to do more on composites.
So he’s going to branch into that a little bit more this year and I thought it’d be nice to tackle an episode about decision making. I want to tap into Mahmoud’s mind. How does he decide when’s it edge bonding, when’s it veneer, and the overall decision making, treatment planning guidelines he follows for his anterior composites. This episode is eligible for CE. We are a PACE approved education provider, and you’ll be able to do that by answering a few questions at the end if you’re on the Protrusive Guidance app.
Dental Pearl
Every PDP episode, I give you a Protrusive Dental Pearl, and this pearl is related to an article I published on the app about top tips on bonding to zirconia.
You see, in 2017, I asked Dr Nasser Barghi at the STA convention Singapore. He’s a big shot in ceramics, right? And I said to him, look, now that zirconia is getting so good to bond with, should we now move away from lithium disilicate onlays and overlays, and should we move towards zirconia? And 2017, he said, listen, zirconia bonding is really good now, but why move away from this wonderful material, lithium disilicate?
I asked the same thing seven years later, so recently at the BACD conference, I asked the same thing to one of my idols, Dr. Chris Orr, and he said the exact same thing. He said, yes, you can bond to zirconia in this strict protocols. But why? When we can do beautiful partial coverage restorations posteriorly that have enough strength and bond just so predictably in lithium disilicate.
So just some food for thought there. I know some of us are doing zirconia onlays and overlays that’s fine, go for it. But I have yet to found a reason to deviate away from lithium disilicate. Well, I’m using the adhesive approach. Now, of course, for resin bonded bridges, I’m using zirconia as well as metal and for my vertical preparations. I am cementing zirconia crowns.
But the top tip I want to give you from that article I wrote summarizing what I’ve learned of the years about bonding to zirconia one top tip is even if you are cementing by using a zirconia primer for example monobond or z prime plus or clear fill ceramic primer something that contains that 10 MDP.
If you use it on the intaglio of the crown, even if you’re not using a adhesive cement afterwards, even if you’re not using resin cement to actually bond your zirconia by using the primer, the zirconia primer, you are actually improving your bond strengths, even with the GIC that you’ll use, for example.
So this is really useful. This is like low risk, high reward. If you have a tooth and you’re crowning it and maybe it’s got less height and you’re thinking is that retention form going to be enough, then perhaps you could still use your conventional cement system, but by using the zirconia primer, you actually get a better outcome. So that’s a top tip I want to pass on to you. Now let’s join this episode on decision making on anterior composites.
Main Episode:
Dr Mahmoud Ibrahim, my brother from another mother, welcome back yet again to Protrusive Dental Podcast. How are you, my friend? Other than sniffly.
[Mahmoud]
Oh, sniffly and coffee and I apologize everybody if I sound like a frog, but yeah, it’s always great to be back talking about a topic I absolutely love. Yeah. So thanks for having me again. How are you, Jaz?
[Jaz]
I’m okay, buddy. I’m okay. I’ve just, you know, on Christmas Day, I hosted my sister and my brother in law and their family and stuff. I had my nephew over, that kind of stuff. It was quite nice. And I did this thing where I went around, only because I really wanted to hear what my son, Ishaan, was going to say to this answer. I just went like, did like a question time with everyone. So I asked everyone like, what was your best moment of the year, right?
[Mahmoud]
People must dread having you over for parties, right?
[Jaz]
I know, I’m like a terrible host. Well, I was the host. I was a host, so I asked him, what was the best moment of your year? Okay. Well, what’s your song of 2024 and what’s one thing that you’re going to change about yourself in 2025? And so before you answer, I’ll say mine just gives you a bit, buys you a bit of time to think of yours. I’ll say mine. Okay. So my favorite song was Hass Hass by Sia and Diljit Dosanjh. So like a Punjabi, but like with Sia.
So it was a nice little remix, which was good. My best moment was probably our family holiday went to Doha. It was. Just holiday, basically. My wife’s was actually our holiday in Tenerife, but that was a different one. So holidays, for us, is a big thing, obviously, so it’s really important. And then, the thing I’m gonna change about myself next year is based on this recent I don’t know if you saw my story recently, right?
That I do my regular blood tests as inspired by Prav Solanki, and my HPA1C, my diabetic marker, just crept up a tiny bit, because I’ve got, like, so many tests worth of data. The cool thing they can do is they can test, they can see the trend and plot the graph, and just a tiny little blip! like a slight increase, right?
So usually for most people, this is insignificant. Like if it was my first test, I’d be like, yeah, yeah, good. But only because they know it’s the trend going up. Did the GP in his report say, hey, mate, you gotta just be careful diet, exercise, that kind of stuff. I felt so bad. And you know what it is?
It’s all that snacking in the staff room that we are the worst, right? All the snacking. So I made a vow to just be a little bit more careful with my diet. Like everyone, my dad’s side of the family is diabetic. So, shout out to Tom Levine, who messaged me a book recommendation on the back of that. He recommended the book, Metabolic, I believe it is by Dr. Lustig. So, just downloaded that on Audible, so I’ll let you guys know next month how it is. But Mahmoud, back to you now, buddy, okay? So, favorite song of 2024. Doesn’t have to be a 2024 song, by the way. It can be a song that represents 2024.
[Mahmoud]
So, a lot of the time, I think I mentioned this song to you before, but Remember the Name by Fort Minor. Okay. That’s a little bit of a hype song. It’s an old song though, so maybe a lot of your listeners might be like, what? Go look it up. Advisory, like, don’t listen to it in front of kids.
[Jaz]
Link in the show notes.
[Mahmoud]
What would I change for 2025? It’s definitely health related though as well. Unfortunately, I don’t need blood markers to tell me that I’m not taking care of myself. I know I’m not taking care of myself. You know, again, it’s just been such a busy, busy year for both of us. I think next year is not going to be any less busy, but I think I just need to get a little bit better at organizing myself and prioritizing certain things. We had a house move, etc. Things are starting to settle back down a little bit now, so I’m going to try and allocate a certain amount of time to just look after myself. Exercise. Eat better and all that sort of stuff.
[Jaz]
I don’t know how you’re recording me right now. You’ve got three kids. I’m two. Now I’m looking like I’m in my little back room. I’m looking across. I see havoc, forks flying in the air. Like I’m seeing it all like from there. I’m just pretending like I’m just recording.
I’m just working right now. But I don’t know how you do it, man. So more power to you. Just amazing what you achieved with three little ones. And so the next question we’ll say, what are you going to improve? And then the highlight moment of 2024. I know it’s been a year with lots of ups and downs and I don’t go into personal stuff and I’m here with you all the way, my friend. Just to remember the positive. Remember the good. What was your favorite moment?
[Mahmoud]
I mean, if I want to do workers, I’ll split it up. Yeah. I’ll split it up into sort of more worky stuff and more personal stuff in terms of best moments. I think probably one of the most fun moments was us in Chicago. I think that was this year, you know, believe it or not.
[Jaz]
Crazy.
[Mahmoud]
It feels like it was a long, long time ago. It was actually this year.
[Jaz]
Like professionally. Yeah. That was also the top moment for me professionally as well. I go with you to meet all our heroes, shaking hands with the Spear, not washing her hand and then shaking her hand with John Kois so that they actually shook hands in a funny kind of way. It was amazing.
[Mahmoud]
He didn’t go to the toilet in between. In terms of personal, it’s not necessarily a specific moment, but over the past like month or two, I’ve actually seen quite a change in the maturity of my older son. Like he’s 11. I actually, at one point I stopped and I looked at him and said, I think you’re getting it.
And by that I meant you’re getting what it means to become a little bit more mature, to become the older brother that your little brother and your little sister need and that your parents need. That was a lovely moment for me. And I think he really felt like really proud that we noticed.
[Jaz]
Cometh. Cometh man.
[Mahmoud]
Personal though. Yeah, yeah, yeah, yeah. That was nice.
[Jaz]
Very nice. Well, about half the Protruserati are like skip, skip, skip, skip, skip. Get to the good big comes big the other half like, you know what? We love this stuff, right? So whatever guys, if you love it, then we love you too. If you don’t love it, I still love you.
Go to the clinical bit, which is now, right? Because right now, Mahmoud, we are discussing a very hot topic. It was always a hot topic. It’s been a hot topic for about 8, 10 years now. Last time I recorded this similar topic was with George Cheetham. Took away so many nuggets. So I had a great time discussing with George, aka George the Dentist, on composite and edge bonding versus veneers, that kind of stuff.
That was really fun. I really enjoyed that. The main thing I took away from that episode, the main lesson I took away, which I just want to echo, is when you are doing bonding with your patient, That initial appointment, obviously so, so important gauging expectations, seeing what’s within your skill set, but just telling them that, okay, if you want to do this dance and we do this together, then the maintenance side of it, let’s have an annual appointment, right?
Kind of like when you have your car serviced every year, right? It’s like a commitment that you talk about right at the beginning. Okay. And you attach a fee to it. Cause I remember back in the day, like, okay, yeah, you need polishing and rebuffing of your composites now and again in the future.
And it’s just like a sentence that you say, but when you actually say, okay, it’s an annual appointment, X fee, and this is your maintenance. If there’s anything chipped or any issues, we will take care of it. We will make them look good. And we’ll also do your examination at the same time, kind of thing.
That was a really nice takeaway from that episode for me. But I just want to build on that because I see your work, Mahmoud. It’s phenomenal, right? Absolutely phenomenal. The resin artistry. You’re a multi award winner now. I know you hate that term. I hate it as well, but whatever. You are, it is what it is, right?
And your work speaks for itself. So I am happy and excited to just extract your mindset when you’re doing this kind of work. And obviously we did the BACD workshop together, British Academy of Cosmetic Dentistry. We did the unchippable workshop. Okay.
You were the workhorse in terms of the beautiful workthat you provided, the demonstrations you did, and you’ve had so many great questions from the delegates. So I’m just going to like go through some of those questions, which are so, so key, right? I guess we have to start with is the decision making process. You have a case in front of you, and it’s quite difficult without a specific case, but just an overarching decision making kind of like flowchart of when would you go for edge bonding?
And just to clarify, I remember doing this and someone on YouTube commented, what is edge bonding? Because in different countries, it may mean different things. It literally is adding some composite to the incisal edge of a tooth, everyone. Edge bonding. Whereas resin veneering is when you take it up the labial of a tooth a bit more. So Mahmoud, what principles can you share with us in terms of decision making and which to do when?
[Mahmoud]
Hmm, yeah, so, I mean, I want to first start by saying George Cheetham’s point is incredibly important, kudos to him, his work’s phenomenal, big shoes to fill, love to get it.
[Jaz]
Sending you love, George.
[Mahmoud]
And I use the phrase to the patient. I say, you need to budget financially and sort of mentally for the maintenance of these, right? Because not only is paying for the maintenance annoying, but also having to attend appointments can be annoying.
[Jaz]
This is just like car servicing. It is literally just like car servicing. I hate taking my car for service. Half a day out of your life gone.
[Mahmoud]
Yeah. Luckily, we don’t get a lot of them, and it’s all the principles that we might discuss today. But I also want to say that edge bonding and veneering, it is not a black or white. It is not one or two. There is no dividing line.
And this really is the beauty of resin. There is a whole spectrum in between from covering just the insides of the edge to doing a full veneer that I do. And I might do three, if I’m doing six teeth on a patient, two teeth might end up here, two teeth might end up here, two teeth might end up here.
[Jaz]
Like a spectrum, like a gradient, right? So some is pretty much on the edge, whereas others edge, and maybe covering up the labial by a couple of millimeters. And the other one might be going shy of the gingiva just by a couple of millimeters. That’s what you’re trying to say, right?
[Mahmoud]
Yes. Yes, exactly. There are certain things I try and avoid. Nobody wants huge, chunky, massively thick composites, whether that is, it’s too thick on the incisal edge or whether it’s around the cervical margin and you’re getting, cause that’ll black trap plaque, it’ll get stained and then you don’t look very good.
So obviously my preference is, treat the case if alignment is needed, do the alignment first and do try and minimize the amount of composite I’m going to apply to the teeth. However, the word minimal seems to always, it’s become cool now to try and put the least amount of composite possible on this tooth to affect some sort of change.
And for me, I prefer to use the term appropriate. It’s the amount of composite that I need to use that will give the patient what they want. So the patient might come in saying I want composite veneer. But actually what you need to dig down into is what is the look they want and then that will help you decide how much composite you need to use and that sort of appropriate amount of composite rather than minimal.
Because I’ll give you a little bit of, just a tiny bit of food for thought here. Just a random example. Imagine you’re doing some edge bonding, yeah? And you’ve covered the edge of the tooth by like a millimetre. Okay, and that’s it. That’s real minimal.
[Jaz]
So purely on the incisal edge?
[Mahmoud]
Purely on the incisal edge, just about a millimetre up the incisal edge. And now, you’re very happy with yourself. You’ve put on a very, very small amount of composite, and it looks good. Now, none of us are perfect. What happens if you get a little bit of staining underneath that margin? Now you go in and you try and polish it away. Now you’ve got very little room to play with, right?
There’s very little composite covering the surface of the tooth that you can polish away. And end up with an invisible margin, still, and a blend that is good. You just haven’t left yourself very much space. If that composite was maybe two millimeters up, feathered down to super thin, and it does stain, you’ve just got a little bit more room to play with. Okay?
[Jaz]
To still I remove the stain, but also to still have enough of a blending zone, a blending transition.
[Mahmoud]
Yes, yes. And I’m not saying I cover the full face of every single tooth because I don’t. I almost never take the composite actual actually to the gingival margin. Okay. Almost never. Because that area is just critical in terms of hygiene, et cetera. So I almost never do that, but there are certain aspects that I sort of consider when I’m trying to decide where on the tooth I’m going to stop it.
[Jaz]
Is there a no man’s zone? Is there a no man’s land? Like, when you’re we’re playing tennis, right? We’re playing tennis, right? You’re either by the net or you’re at the back. You don’t want to be caught in no man’s land because like it’s really difficult to play shot. Did you know that? Did you know that about tennis?
[Mahmoud]
I’ve heard about it. Yeah, I don’t play tennis.
[Jaz]
I know you’re talking. I know you’ve shown some images before. I love this term, right? And maybe if you want to screen share this, for those of you who are more visual here, the chasm of crap. It’s a great time. Chasm. Okay, fine. There we are. See, English is my second language, alright? So, go with me. Third language. Okay, fine. The chasm. Are you sure it’s chasm? Because I like the word chasm.
[Mahmoud]
It’s a chasm, dude. A hundred percent it’s a chasm.
[Jaz]
I don’t know what that is. I don’t know what a chasm is. So, there we are. What is a chasm?
[Mahmoud]
Like a valley. Like a-
[Jaz]
The Valley of Doom, the Chasm of Crap, which is cool because it has more alliteration, I like it. So, the Chasm of Crap, as Mahmoud once so brilliantly illustrated, is like, if you finish your composite like in a random place on the labial surface, then you get this like little con cavity, whereby it just collects stain.
Can you share your screen or not? Have you got that image to share? Tell us about this chasm of crap and this area where you get like this mid facial stain. How can you prevent that? And is that a guideline that you use in terms of where to finish the resin?
[Mahmoud]
Yeah, a hundred percent. So what I don’t want people to do is have the composite on the edge of the tooth, sort of meet the tooth in like a depression, right? So my guide as to where to end the composite usually is the height of contour of the tooth. Why? Because that allows a smooth, smooth blend. If you end below the height of contour of the tooth. What happens is you get the thickness of the composite and then it dips down into the tooth and then the tooth starts again and you have this like, little V shaped depression between the two.
A, it’s impossible to polish. Like, you’re polishing it, polishing, polishing it and you end up with like, this white line. But also, it’s impossible for stain not to get caught in there because the patient can’t brush it very well. That’s why I call it the chasm of crap because you always end up with like pasta sauce and stuff after they’ve eaten.
[Jaz]
Just for the students and the young dentists who are maybe new to the term height of contour, it’s kind of like the maximum bulbosity in like the gingival third often area, just slightly maybe more incisive than that. And it’s kind of like a good reference point whereby you can put your probe and then, I’m just trying to visualize how to explain this concept to someone who, because we get this question sometimes in the podcast, how do I identify the height of contour? Any guidelines you can give. So like using an occlusal mirror maybe.
[Mahmoud]
Yeah in a way I mean, okay, so this is why this really does need to be done on a course. But it’s the height of contour relative to the composite. So if you imagine your final facial surface of the composite and whatever angle that is at. What I want that composite to do is to then meet the tooth, and then the surface of the tooth continues that same trajectory as the face of my composite, right?
So, that’s how I want you to think about it. Because the position of that height of contour is going to depend on the inclination of the tooth, going to depend on the shape of the facial surface of the tooth, and it’s also going to depend on the angle of your composite, right? If your composite is, really flat up and down, really quite thick at the incisal edge, then the height of contour it’s going to meet is going to be up by the cervical area, right?
If your composite is quite thin, rolled inwards incisally, which is something we’ll talk about as well, right, then its trajectory is a little bit more out to the facial. It’s going to meet a height of contour maybe slightly earlier, right? If the tooth has that incisal curve naturally.
[Jaz]
I think the most important thing to grasp here is that as you take a probe and you take it from the enamel to the resin, it should be seamless. There should be no catch. There should be no depression. There should be no chasm of crap where we’re staying, we’ll do. But the other thing to not do the opposite is don’t just have like a tooth and then edge bonding, like just composite completely glued the edge of the tooth. But you have a great visual for this, which obviously for the purpose of the podcast, which shouldn’t describe, describe the issue there. In terms of having composite just glued to the edge of the tooth.
[Mahmoud]
So the problem there is mostly optical in nature. You’re asking two completely different materials to behave optically similar in order to fool the eye so that the person looking at this tooth doesn’t see a join between the composite and the tooth, right?
But you’re going from an area where the composite is that is sort of 100% composite thickness, 0% tooth thickness, and to immediately go on to an area that is 0% composite and 100% tooth thickness. And those two things cannot act optically the same very easily. It’s better that you have a gradual change.
So you go from an area that is completely composite which is basically the edge of the tooth that you’re adding to, right? And that ratio of tooth to composite gradually changes as the composite lips over some of the tooth structure so that when the light hits it, it’s going through a little bit of composite and then a little bit of tooth.
And that ratio will gradually changes from a lot of composite towards the incisal edge and less tooth to more tooth and less composite as you go further up the tooth, depending on how much composite sort of you lip over the edge.
[Jaz]
So you’re right. You don’t want to go from like composite to tooth in a harsh way. It needs to be composite to a bit of composite bit of tooth to then tooth only. But that needs to be like a nice seamless blend. And I think there’s so much in the whole episode, two episodes, we can talk about characteristics and techniques and top tips to get like an invisible blend and stuff. And we could talk about days for that, but just more on the decision.
[Mahmoud]
We literally do on the course.
[Jaz]
But in terms of edge bonding and resin veneers, you’ve kind of made it quite clear that it’s a spectrum, right? When you’re doing a resin, you’re deciding case by case, and it can finish anywhere on the tooth, depending on that specific case. But then there are-
[Mahmoud]
I want to split it up a little bit. And to like, just to summarize, you’ve got your aesthetic reasons, but we also cover things like, your unchippability reasons, right? The reasons for strength or longevity. Aesthetic reasons to cover more of the tooth, obviously if you’re changing the color, but slightly less obvious ones if you’re changing the texture of the tooth.
So if the patient’s enamel has natural like pits and stuff and they want to get rid of that. Sometimes the tooth has sort of banding that you can’t get rid of with whitening or icon. But one that might not be so obvious is I do tend to change the shape or even the apparent shape of a tooth a lot by changing the position of the line angles.
Now, I can’t do that if I don’t extend the composite up the facial of the tooth a little bit more. So those are just a few of the considerations I’ll make, especially if you have fairly triangular teeth and you’re trying to change them, you have to cover a bit more of the tooth. And then when we talk about longevity, that’s when we start talking about composite thickness, angles, and things like that, which we’ll get into.
[Jaz]
I think when we’re talking about edge bonding, let’s composite again, and we talked about, yes, this spectrum is in between zone, but there is something that is more of edge bonding, there’s more of a resonating.
And like you said, sometimes you do the other mode down for color change, for example, more major shape change playing about with the line angles. When we’re doing that kind of work and that distinction in a way, are you using different materials? Do you think that, okay, because you’re doing more of an edge bonding, you’re going to use a certain type of composite, or because you’re doing more of a resin veneering, or you’re trying to achieve a different objective to do with either shape or color, are you changing the composite that you’re picking up?
[Mahmoud]
Not necessarily for whether it’s edge bonding or the composite video. So there are certain decisions that I make or survivability reasons. So I’ll give you one example that’s not to do with the type of material. But for example, I don’t charge differently, right? I don’t charge. I don’t have two separate charges for composite edge bonding and it comes with a veneer. Okay, I do get patients ask how much is this versus this. It sounds exactly the same.
[Jaz]
It’s a per tooth fee.
[Mahmoud]
It’s a per tooth fee because I want to be free to do what I need to do again to give the patient what they want. So that’s one. Second, the choice of material tends to be based on, so we tend to categorize our patients into a HORP or a LORP. So for those who don’t know, a HORP is a high occlusal risk patient. So it might be a patient that has huge masseter muscles, a patient who we can tell maybe grinds their teeth.
They’ve got attrition, tooth to tooth rubbing, right? That is a high occlusal risk patient versus a LORP or a low occlusal risk patient. The patients have still lovely mamelons on their teeth. You can see all the insides of halos and stuff. They don’t grind their teeth. Their muscles are quiet or not hypertrophic.
So if I am dealing with a patient who I consider to be a HORP, I will almost always default to using a material that is more chip resistant, more so stronger in the sort of areas that receive a lot of load for me personally, I prefer to Venus by Kulzer. That’s what I use. If the patient is more of a LORP and I am aiming for more intricate sort of layering, I’m going to have some fairly weak materials at the edge anyway, because of the tints and things like that, then I might still use Venus as my palatal backing.
To gain a little bit of strength, but then for my layering and stuff and tints, I’ll use either Cosmedent’s Renamel. I use Filtek Supreme XTE and I use Tokuyama Estilite. Those are sort of my three go to that I sort of mix and match.
[Jaz]
So a nice distinction there, high occlusal risk versus low occlusal risk. And that’s important for decision making, unchippability as we like to call it. Next question then is in terms of getting a good result, how important do you think is it for our colleagues to be thinking about layering, right? Because me, I’m a one shade wonder. You know that, right? I’m always a one shade.
All my cases I show, the course stuff, online, I’m just like, hey, I’m going to use one shade and I’m going to do the best I can with that one shade. Like, as I often joke, but it’s kind of true, is my speciality is getting someone from a 4 out of 10 to like a 7 and a half out of 10. You are there taking 7s and turning them into like 10s, right?
So that’s the difference between me and you. But how much of that do you think is due to layering? I’ve never actually asked you, what percentage of your cases are layered versus just one shade wonder.
[Mahmoud]
So I think if you want to make teeth look more natural, like with your incisal effects, it really comes down to two things mainly. Okay. How are you going to cover the transition between the tooth and the composite? And do you want to add incisal effects or not? Those are probably the two biggest decisions you need to think about in terms of whether you’re going to layer or not. If you don’t want to layer, you want to use a single shade, then you’re not going to be able to add incisal effects, so forget that.
So if it’s a patient who wants that, you’re not going to be able to give it to them. Do patients ask for that? Not really. I tend to get patients who ask for that, but I think that’s because that’s the work I put out. But in general, patients don’t tend to care. But it’s then about how you’re going to cover the transition between the tooth and the material, okay?
If you don’t have enough thickness of composite, the composite might be a bit too translucent and you’ll see that grey line, you’ll see the transition between the tooth and the composite, in which case you might need to resort to a lot of beveling of the tooth, create thicker bit of composite at that graduation where it changes from mostly tooth to mostly composite. That’s where you need to maybe heavily bevel.
Interjection:
Hey guys, just Jaz interfering here. I hope you’re enjoying protrusive content. Hope you enjoyed all the content throughout the years, and there’s so much to come. Now, if this year you’re wanting to learn how to do Vertical Preparation, as you know, I’m a huge fan of Verti Preps, as you call them.
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[Jaz]
See, remember, with my older patient base, they’ve already got like, worn teeth and chipped teeth and jagged edges, so for me, that’s very easy to do, hence why I get away with it, I get a good blend, because again, I make that shape, and I am able to bevel and add my one shade, which is gonna be good enough for that patient in my population, based on the village that I work in, but for your patients, yeah, they’re younger.
I’ve seen them. They’re younger and the kind of work you put out and they’re trying to small transformation to do. They are the more cosmetically focused patient. And so I see what you mean in terms of even if you’re going to use one shade, you are perhaps not in a position to bevel or bevel aggressively because of the fact that you are dealing with quite nice enamel already. You don’t have to scratch it. Is that your thought process in that scenario?
[Mahmoud]
Yeah, but it’s also even more. It’s even trickier in that sometimes, because if the tooth is intact and you still have the incisal one to two millimeters, it’ll have the halo, which tends to look quite opaque, and then you have the band of translucency in the incisal edge.
And what’ll happen is if you put a thin bit of composite on there, you’ll actually still see those things through, and it’ll look really weird, because you’ll have a really thick band at the bottom now, where your composite is, and it might blend okay onto the halo, but then you’ll have like this gray bit in the middle, right, which looks really, really weird. So my preference, and I call this sort of transporting the incisal edge, yeah, is I use opaquers in the area of that. So the natural translucency of the tooth.
[Jaz]
And it is like flowable?
[Mahmoud]
Yeah, flowable opaquer is because they can be very, very thin.
[Mahmoud]
That is a white opaque, if you like, but then you can get opaquers that are either vita shaded, so the ones that I like to use, or they’re shaded as A1, B1, A2, whatever.
[Jaz]
Or would they be A01, for example, over opaque that? Is that kind of how they term it?
[Mahmoud]
These aren’t named like that, but I guess different brands can call them different things, right? I don’t know. So the ones I use are the Cosmedent ones, and I’m not sure that anybody else makes vita shaded liquid opaquer. I might be wrong. Someone correct me if they know otherwise. Those are the ones I use because they are vita shaded. So they’re not bright white. They will match the vita shade as close as possible.
[Jaz]
The shade that you use here, for example, let’s say you’re going to create, you’ve done some teeth whitening, okay, because patients want to have white teeth if possible, and then you’re going to go for a bleach shade or BXL, whatever, that’s usually a modal thing. I don’t know how often you do that.
It’d be nice to know. So, does that mean that the opaque- Okay, I thought so. Phew. Does that mean that the opaque you’re going to use is going to be the same shade as the shade you’re aiming for, or you’re trying to go halfway between to try and create a blend or transition? What’s the thought process in terms of the shade that you use?
[Mahmoud]
No, if I’m aiming for a bleached shade tooth, then I’ll use the A1B1LO, it’s called, by Cosmedent, and so it covers everything from A1 to LO. What I would use for teeth that have been bleached, okay, they have a B0, which is even lighter. But I very, very rarely use that one because it’s like an internal shade that I’m trying to sort of mimic the dentine, if you like.
I don’t really want it to be super bright and then shine through unless I’m trying to aim to give the tooth those like hypercalcifications or a brighter halo. I’ll use it there. But otherwise I stick to the A1B1LO in a lot of cases just to hide that grayness of the natural translucency of the incisal edge, cover that, and then I move it more incisally using then my gradient to mimic the new translucent band. Does that make sense?
[Jaz]
Yeah, yeah.
[Mahmoud]
So there’s no way I can do that if I’m doing a single shade.
[Jaz]
And so how often are you doing a one shade wonder, versus how often are you using tints and layering? So basically, how often do you get a HORP? How often do you get a LORP?
[Mahmoud]
I’m probably seeing a lot of lorps at the moment, because you tend to get a lot of people who want nicer looking smiles, but it’s mainly that they’ve got misalignment. You do the invisalign, you do the ortho. And then it’s just about tidying certain things up and the more we look at patients and the more we realize maybe the envelope, maybe it’s envelope issues, we talk a lot about restricted envelopes of function, your lack of overjet, et cetera.
And if that is what I think is making the patient a horp, right, once I’ve resolved that with my ortho, I’ve given them a little bit more overjet, I’ve undeepened the overbite, then I’m maybe a little bit more free to then layer and use the materials that I can get a nicer aesthetic result with. Whereas if it’s a patient who I can see clearly, is grinding their teeth, even maybe even during the Invisalign, you can see that the aligners are getting worn out and they’re cracking them.
Then no, I’m going to go single shade. I’m going to go with Venus, more than likely Venus pure at the moment. That’s like my favorite one. Yeah, I’d say that’s probably like 30% of my cases. If I put the pictures up side by side, could I choose an absolute personal sort of favorite way of doing it?
Me personally, like, obviously I love the layering aspect, the artistry of it, it’s just so rewarding and it’s so much fun to do. But a patient wouldn’t tell the difference, I don’t think. Unless it’s a blown up picture and they say, I want that, fine.
[Jaz]
Okay, well, in that scenario then, when you’re considering layering, do you always do it whereby you’re being like a 3D printer? You’re like, you’re making the palatal shell, you’re then adding this tint, that tint, that shade, it’s like a recipe book that you’re building, and you’re building a layer upon layer upon layer, and then the final enamel layer, and then polishing it back versus MHM, Marshall Hanson. That’s the Marshall Hanson method.
I see a lot of his stuff online. The cut back his technique. Basically you do the one shade like I would do. And then like the next day or the same day, I don’t know when you do it, like in 48 hours, whatever you cut it back. Like you would do an EMAX, right? And then you bake all your tins in. Okay. Have you ever done it that way?
[Mahmoud]
I have, I’ve done it. I’ve done it, but in the same appointment. So I’ve done cut back. So built the entire shape, get the shapes, right? I think the biggest benefits of it is what scares people from using tints or layering translucent masses and stuff is if they get them in the wrong place, whether it’s gingival incisally in the wrong place, or whether it’s buccallingually in the wrong place, then when you come to finish and polish it, it’s going to look like crap, right?
You’re either going to have too much translucency, too little translucency, you’ll get rid of your halo, or your halo would be too thick, or whatever. So the idea with that is if you get the shape perfect frame is perfect, then you can cut back and you know where you need to put your effect and they will look good.
So that’s mainly what they’re trying to avoid is getting the effects in the wrong place. I have a pet peeve. I think this is from my childhood, honestly, I love you mom, yeah, mother, I love you. But there is one thing you do. You’ve always done this and it pisses the hell out of me.
It’s like repeating stuff. I hate being told the same thing seven times, but I also hate having to repeat something I have already done. Whether it’s through my fault or, or not, I just don’t like it and I don’t like repeating myself. When I did the cut back thing, when I cut it back, layered everything in and then was doing my finishing and polishing, I was like, oh my God, I’ve already done this.
And now I have to do it again? And it was really, really annoying. So for me, I don’t like doing that particular method. It has huge advantages as well in terms of the technique he particularly uses in terms of making things stain resistant stuff. Phenomenal technique. I know someone who’s gone on his course in the US and brilliant guy.
For me, I prefer to just do it once and get to the end and hopefully be happy. How do I avoid the pitfall of getting things in the wrong place? Couple of things. A, I always make sure I assess everything from multiple directions. And honestly, people talk about looking at your composite work incisal view.
So take a mirror, put it sort of in the patient’s mouth and look at the teeth as if you’re staring up its incisal edge. That’s one thing, but you need to also look from the side and do the same thing. Hold the mirror on the buccal of the tooth next door and look at the buccal side of the tooth. You can see like if someone’s watching me work, my head is moving around all the time.
And hopefully, I’m going to be sharing some of those workflows in the next year or so. And you’re going to see how much my head moves and what I look at. And even when I’m layering like my final composite, I’m not always looking at the tooth dead on when I’m actually placing the composite. I’ll be looking at it from the side.
[Jaz]
The one that Nick’s saying the whole time, man.
[Mahmoud]
Yeah, I know, I’m wrecked. But I get the patience to move as well. That’s one. But also, try and perfect each step before you move on to the other one. So you’ll also see, for example, when I do build my palatal shells, whether I’m doing it freehand, whether I’m doing it from a mock up or wax up, whatever, I will then adjust the edge of that palatal shell so that it’s the correct length, it’s the correct width, before I move on to the next step.
Because if you don’t, that could alter where your proximal wall might end up going, right? If you leave the incisal edge too broad, you might move your proximal wall back. So if the edge is too long and you haven’t cut it back, then you might put your halo on and it’s in the wrong place. Right? So I just make sure that each step is corrected.
I’ll take a disc, I’ll correct it, then blow the powder off with some air and then I just get some modeling resin on a brush and I’ll just wipe away any of the remaining powder and I can just carry on with my layering. But that’s how I make sure that where my halo ends up is where I want it to be.
[Jaz]
Because the last thing you want to do is put all this extra work, we’ve all done it. And then you just get away and then what’s the point of creating all that incisal halo and transducency if you’ve just adjusted it away. And that was one of the questions I was gonna ask you actually, is that when you’re doing layer by layer and you’re trying to get things right and then you’re cutting back and you’re adjusting, how do you get rid of that dust?
Well, we’ve answered it, air and then modeling resin. And so the other thing which this naturally leads to then is because you’re doing all the layering, right? And 70% of the case, you’re doing layering. Does that mean that in 70% of the cases you have a wax up? Because I do one shade, I can afford to do a lot more cases freehand, right?
What advice would you give to those listening about the need for a wax up? Because if you don’t know where your edge is going to be, if you don’t plan this, bake this in from the start, you’re going to get to a big mess, right? You can’t freehand a layering job.
[Mahmoud]
Agreed. So I would say my objective and however you want to get to it is up to you and I’ll give you some options. My objective is that I want that patient to have a preview of the expected lengths of the new teeth before I book them in for a really long appointment to treat them. How do I do it? I personally, most of the time I do a freehand mock up. So as you like to say, you’ll take your expired composite. Without no etch, no bond, I will mock up the new incisal edge length, the new incisal edge shapes.
You know, how big are the embrasures? I like fairly open embrasures. Some patients don’t, and I want to pick that up now, right? And I want to explain to them why the embrasures exist and why it’s important. And then once they have approved the mockup, so, I might need to adjust it. If they think it’s too long, I’ll shorten it.
If they think it’s too short, I’ll lengthen it. This is all done freehand. This is done no etch or bond. I can do whatever I want. Right? I can tell them, actually, no, I can’t make it that long because you’re going to chip it. Whatever.
[Jaz]
Are you doing just incisor palatal here? Like-
[Mahmoud]
Yeah, yeah. Most of the time. You could do full volume, but I don’t for a couple of reasons. A, it would take a long time. It’s a lot of composite. B, if I give that patient a mirror with this mock up, yeah? Which is like literally just palatal shells. And they go, oh, I love it. You know, I can’t wait. So excited to get my new smile.
And they’re all like giddy and stuff. I’m going to take selfies. I know that when I do the actual layering and it’s not half of a tooth. They’re gonna be over the moon, right? If they start going, oh, but it’s like, you know, and they shove the mirror like here and they get their microscope out, then I’m thinking, okay, this is gonna be a little bit, just book a little bit longer.
Maybe things might get a little bit more filling right? Just gives you a little bit of an insight into the patient, but it’s also a lot quicker. Like, I wanna be done with this mockup in like 15 minutes. I don’t wanna be there for an hour shaping everything. If I have a reason to think I need to, like if it’s a diastema closure case, right?
And I’m figuring out where am I gonna add the width, right? Because sometimes I’ll give a little bit of width to the centrals, a little bit to the laterals, a little bit to the canines, maybe sometimes you’ll give the laterals a little more, whatever, right? Then obviously you need to build up your proximal walls, because I really want to get a good idea of what the proportions are going to be. Harder to do that by just adding to the incisal edge.
[Jaz]
Case by case, but you could do a lot with incisor palatal, as you said, and it’s a great tip about gauging expectations. I actually love that so much. So, I mean, that helps to answer. And so really you’re using that as your wax up, you’re taking a putty of that, and then you’re using that in the future.
But how often are you doing, you actually using, because I know you’re doing wax up. How often are you getting the wax heater out and doing wax? And do you ever use the lab for either a digital or a traditional wax up?
[Mahmoud]
Yeah. So I will use a lab for either digital or traditional wax up if I don’t think I will have time to do it myself. So over the past 12 months, for example, we had an absolute ton on and I knew that every minute I had, I had to put into the content, the lectures, blah, blah, blah. So I did get a lot of self lab made stuff because I’ve kind of been there and I’ve done that. And I’ve learned a lot from doing the mix ups.
Now anyone’s listening hasn’t done their own wax up, man. Please, please. I beg you just do one. Do one, even if you do one tooth, you will learn so much about tooth shape. If you get the models articulating stuff, you can learn so much about occlusion. It’s hugely mind, eye opening, but yeah, I’ll get the lab to do it.
If I don’t think I have a lot of time and one tip I do, I can give sometimes is what I’ll do is I’ll collect my data up front. So I’ll do my photos. You do your x rays, you do all that sort of stuff. You’ll do your smile design and I’ll do a mock up of maybe one or two teeth. Intraorally.
That’s it. Okay. And then what that will set is because I’ll do the centrals. For example, that’ll set my incisal edge position. Which also sets the incisal plane, because you’ve got two teeth, they’re horizontal. Now the lab know that has to be the horizontal of the smile, and the incisal edge length.
And they’ll know where the midline is, because I’ll either put it using my embrasure, or it’s already there. And I’ll take a scan of that, as well as the scan of the upper and lower teeth without those things. So flick them off, and take normal scans. Those will go to the lab. The lab will make me my whitening trays. And they will send me back a wax up.
[Jaz]
So it’s like, I’ve kind of done a little bit of the work with the direct composite mock up technique, but then you get in the lab to do the rest with the either digital or traditional wax, right?
[Mahmoud]
Exactly. They’ve got those two teeth. Once you’ve got the incisal edge position and the photos, they can then digitally design everything else. Now, do you need facebow? Do you need fully mounted on a physical articulator to do these things? Now, if this patient is a lorp, and I’m not super worried about occlusal risk, and the lab have the incisal edge position from what I’m giving them and they’re just going to fill in the blank, then no, I don’t think you do.
I’ll just get the wax up back. And like I said, my objective is I need this patient to have a preview of their new smile before they say yes. I don’t care how you do it. This method, I will take putty index of the wax up and I’ll use some temporary crown bridge material. So my preference, luxa temp, and I’ll do a mock up on the patient’s teeth.
So no etch no bond. You fill the putty stent with your lux attempt, seat it over the teeth, let it fully set, take the putty off, and then they can have a look at the new lengths, just the new aesthetics in general. You can have a look as well. And most importantly, you can see whether you like it or not.
Did they actually match the incisal edge position? Is the midline straight? Is the smile canted or not? And if everything’s okay, and guess what, you’re fine. You can go ahead. And the beauty of it, it’s all composite at the end of the day. So even if there is slight adjustment you need to do at the end, you can. Now, if the patient is a horp and I’m designing canine guidance, group function, transition to crossover, blah, blah, blah, all that sort of stuff, then yeah, obviously I’m going to put in a lot more effort.
Maybe you’ll get the models mounted and plan the case appropriately. So that’s what I do, but I want the patient to have a preview. 100%. Okay, that is non negotiable for me. So, some people do it where you can have like a video call with the patient and then they come in straight for treatment.
I have never done that. I will never do that. That just sounds like a headache. So they will get a preview. I’ll get a preview and I’ll either have a wax up from which I’ll take palatal putty stent or I’ll have my own mock up in which I’ll make a palatal putty stent. Very occasionally I’ll do the mock up and if I’m lazy, I can’t be bothered.
But it was like a really predictable mock up. Like I knew exactly where I was putting everything. Then again, they’ve seen it, they’ve approved it. I’ve taken photos and then I’ll just freehand it when I come to do it. But I kind of, again, I’ve already in my head, I know I’m adding a millimeter here, adding a millimeter and a half here or whatever, I know it.
[Jaz]
That comes with the skill and experience. I think that the main takeaway here is give the patient a preview. And it also is an opportunity to gauge their sort of expectation and beware the chasm of crap. The three things you take away from this episode. And also it’s chasm, not chasm. Thank you so much for giving so much for sharing so much of your secret source.
There’s so much we still have to discuss. We’ve got the Unchippable course also launching now as part of our family of education that we provide. Our jingle should have played, I think somewhere in the middle of this, which I’m hoping people got pumped about, but sorry, we’re just going to say something.
[Mahmoud]
Well, no, I was just going to say there’s two other considerations that make me think, make me decide between whether it’s going to be a veneer or whether it’s going to be purely edge bonding. And it also can impact how many teeth I then need to treat. And these are ones that people probably don’t think about.
Now that you’ve mentioned Unchippable, obviously we go into these a lot in detail into in Unchippable, but we are about, I want people to listen to this episode and really take something a way that will help them. And it is, you want your composite to have a minimum thickness, right? But you don’t want your composite to be super thin on the edge.
And if you think about it, wherever that incisal edge needs to be, and it needs to be, let’s say, a millimeter, a millimeter and a half thick, that then translates into where the facial of your composite it’s going to have to be right. And then that could dictate whether the composite ends up being a veneer or just an edge bond.
Now let’s say you’ve got teeth that are misaligned. You got one tooth that’s a little bit more buccal onto it a little bit more lingual and you need that edge thickness. Now one tooth might end up being veneer. One tooth might end up not being veneer because if you veneer both, they’re going to again still be different facial thicknesses.
And this is where obviously pre restorative alignment becomes really crucial. You want that minimum thickness. So think about how that’s going to affect the. facial position of your composite And the last thing we talk about, and again, this may be a little bit more complicated than a podcast episode can take, but it’s palatal angle of the composite.
And I want to make sure that that angle isn’t too upright or too, what we call steep, right? I want it to be shallow, as in it’s coming out that way, so down and out on the upper. I had a case in just yesterday. She had some porcelain veneers fitted about a year and a half ago. And she came in and I don’t know where she had them done, but one of the veneers was out already.
I looked at it and it is really odd shape. Put it on the tooth. And honestly the incisal two to three millimeters curled politely. So far the tooth looked like a talon. Yeah. It looked like that on all this bit down here was ceramic. Once again, just imagine how this lower tooth when the patient’s chewing and stuff, it’s far more likely to knock into that added length because it’s going in. So I’m going palatally.
[Jaz]
Which is natural to tooth have a feature and sometimes in certain genotypes it’s more, or phenotypes, it’s more pronounced than others, and you have that curvature, but when we’re doing restorative dentistry, we know to bake that into your restoration is a dangerous thing for the envelope function, for the envelope parafunction, for so many factors there, so yeah, I can see how that would lead to an issue.
[Mahmoud]
Yeah, because if it’s the patient’s own enamel, right, and they wear it and stuff, they will come to you and say, okay, my teeth are worn, could you fix them? But once it’s your restoration and it breaks your chips, now it’s your problem. So that for me is, I always try and maintain the existing palatal angle of the tooth or shallow it, try not to steepen it.
So again, that will have an impact on the facial thickness of the composite and therefore it’ll have an impact whether it ends up being edge bonding or full facial veneer. These are difficult concepts to explain and understand without visuals. But we do spend a lot of time on self and chippable talking about these two things, which I think are crucial.
They are probably the two biggest decisions that affect whether I do veneer or edgebond. And whether or not I might say to the patient, actually, no, I can’t do just your two centrals. Because I’m gonna have to build them out and then you’re gonna look goofy. So we do the other two.
[Jaz]
What I want to finish on is just to reassure everyone that, you know how they said, okay, the market is saturated. It’s too many composite courses out there. And we thought about it. Oh my God, there’s a gazillion composite course out there. But the reason why me and you had no hesitation to come out with this is because this is not a composite course. Cause you’ve been on way more than I have. Like so many, I’ve been on a fair few.
No one’s ever talked about the kind of things that we’re going to talk about in the sense of actually getting longevity. They talk about the beauty, they talk about form follows function to some degree in the form and the shapes and whatnot, but how to actually put that in to your patient’s mouth that has the hypertrophic muscles, that has the high risk features, that has got an advanced amount of wear, and how you might mitigate-
[Mahmoud]
Identifying the high risk features. That’s where it starts with, right? And then nobody talks about that on a composite course. And it’s about not treating the wrong patient with the wrong modality.
[Jaz]
Correct. But then also when you treat a high risk patient, the different recipe and the rule book, which actually goes against some aesthetic norms. But if you go on composite course that we’ve been on, for example, and then you follow that recipe and hawk two years later, you’re going to get that chip. You’re going to get that break. Hence why we called it a very bold name. I remember being sat next to a very nice man at the BACD dinner. And he said, we looked at your topic on Unchippable and we thought that is very, very difficult to teach.
It’s amazing. We love the name. But we thought that was very, very difficult to teach, but we’re very excited with the prototype at BACD went very well, got loads of content. I think we’re going to be a hybrid model. So give lots of people some online learning as much as possible at home before they come in, because this is the future of education, right?
So that they can do as much hands on as possible. And that’s kind of model we’ll follow. So Mahmoud thanks again for everything, my friend, for being on here, for sharing your secret sources right to the end moment, and I would encourage everyone to follow Mahmoud on Instagram. I’ll put his handle in the show notes. And of course we’ll catch you next time. Thanks, buddy.
[Mahmoud]
Thanks dude.
Jaz’s Outro:
Well there we have it guys. Thank you so much for listening all the way to the end. Hope you enjoyed that geeky discussion all about decision making in anterior composites. This episode is eligible for CE, so if you’re on the Protrusive Guidance app, scroll down, answer those questions, get 80% and Mari, our CPD queen, will email you a certificate.
Mari actually emails you a certificate and every quarter, she’ll email you again a summary of all your certificates and then annually will send you a review of all the certificates that you gained. So do check that out on the Protrusive Guidance app.
Now, really importantly, if you love what Mahmoud teaches and his resin artistry, then you want to get on the Unchippable course. This is the first course of its kind that tells you how to make these composites beautiful, but actually gets them to work in your patient’s occlusion. This is not an occlusion course, but this is not just an anterior layering course. It is a beautiful marriage of the two. So how to make your teeth look good and last a long time.
All about anterior dentistry. We’re thinking of doing a few locations throughout the UK this year, and maybe internationally in the future. But join the waitlist www.protrusive.co.uk/unchippable. I know what a wonderful name, right? That’s /unchippable. Join the waitlist. Enjoy the revolution of actually doing these anterior beautiful restorations but sleeping well at night knowing that they’re not going to chip.
We’re going to tell you all our secrets but the hands on element will wow you. We also have like an online course that you join before the course so that on the live course we can focus two days on hands on as much as possible. That’s protrusive.co.uk/unchippable to join the wait list.
Thank you once again for reaching all the end. I’ll catch you same time, same place next week. Bye for now.
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