Why Injection Moulding Composite is Superior to Layering – PDP228

Teaser:
I’m glad you mentioned it, that you are so convinced and dedicated to the injection moulding way to deliver a restoration that you’ve pretty much now found ways. As long as you can make your scaffold. 

On the mesial distal, you have some composite with just one shade. Now this brown area is much more evident than before. So the patient completed the appointment. Saying, I am very happy. I have no more black triangles. I am very happy. But when you’re doing a study patient with the worn dentition because of occlusal problem, if you are going to do, for example, an important canine guidance, an important incisal guidance, they’re going to break everything after a while.

But honestly, when I see with air drying the restorations with magnification, and I see the interproximal surfaces in comparison to the surface that I have with injection moulding with matrices. This surface- 

Is there a composite that you found to have superior longevity in terms of color stability, polishability? Is it a 3M Filtek? Is it Estelite? I dunno, what are you preferring nowadays? 

Okay. What I use every single day in my life is I use- 

Jaz’s Introduction:
Protruserati, there’s been a big shift over the years towards injection molding. Now, some of this has been driven by the industry, of course, right? So we always have to be careful about biases.

Biases are everywhere. Now, use this technique, use that technique because there’s a lot of money involved for these companies. But what I look for is clinicians that change, that pivot from a technique that’s perhaps established and we know of, and they pivot and change to a different technique. And if they can justify why they’ve made that change and share the science or the rationale, I like when something is justified.

There is a clear science behind a decision that’s made by a clinician that’s fantastic. Rather than, oh, this company’s paying me. So I’m talking more about this product. This is why I really respect today’s guest, Dr. Marco Maiolino. We’ve had him on as a guest before on the imperfect dentist. He is such an authentic character.

He talks about his failures very openly, and it’s his failures in layering over time, right? He shares the long-term data of seeing his composites and he is a very good practitioner. High quality isolation, high quality materials microscope, everything. But what he noticed at the eight, 10 year mark is that his layered composites were not looking very aesthetic despite using the best materials and best techniques.

They certainly did not look as lovely as they did at day one. So many years ago. He moved, I believe he said 2014, he moved towards injection molding. Now when I say injection molding, you guys probably think, oh, exaclear or memosil stent, and then you inject the genial injectable composite or any other composite that may be available.

But actually, injection molding is just the name of the technique, the act of injecting into a space. So this could be bioclear or these transparent matrices. It could be just a humble mylar strip behind a tooth, and then you inject the composite into that space once you’ve made your scaffolding. 

So really, this episode is about the process of injecting that material and why the injection of composite is superior according to Marco than layering bit by bit and some of the issues that you can face with that, and why in the long run, whilst your layered composite may look a little bit more beautiful, a little bit nicer on day one compared to your injected composite, when you look at them at eight, 10 years, the injected composite looks more consistent, more stable, both types of color. Luster, shape, all those things. So there is a science behind it. And to discuss that science we have Dr. Marco. 

Dental Pearl
Hello Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode I give you a Protrusive Dental pearl. Today’s pearl is something I shared a few weeks ago on our community Protrusive Guidance, the home of the nicest and geekiest dentist in the world.

And it’s about my thoughts on shade selection on composite. Now, in previous pearls, I have discussed the button technique. Getting a small button of composite, curing it, and then having a look. Hmm, does it match the adjacent tooth? Is this gonna be the right shade to use for my patient? And in another episode we did with Dr. Jason Smithson, he talked about using a black and white photos. 

So as you’re doing the shade test, you taking a black and white photo of your patient, you can use a phone for this and see, hmm, what’s the blend looking like in this black and white photo. But I’ll tell you one thing I’ve picked up through experience call it wisdom.

Call it Learning from Failures, is that if I’m not sure, between, let’s say an A1 and A2, just to make it really easy to understand and clear if I’m unsure. Ah, it’s kind of A1. It’s kind of A2. They’re both matching. Please, for the love of God, use A1. Okay, use the lighter shade. 

In my career so far, every time I’ve opted for this, slightly darker, ’cause this will match better, it’s been more risky and in some occasions it just wasn’t light enough. I’ve been disappointed at the end, and there’s more risk that the patient will say something that, ah, they’re not a hundred percent happy. But where I’ve used the whiter shade, then you know what, no one ever complains.

Everyone’s happy. I’m happy. And I just made it a rule. Okay? My rule is if I’m undecided between two shades, whichever one has a higher value, that’s the one I will use. It’s a really stupid thing, really, but sometimes when you are stuck in that scenario thinking, Hmm, what do I do? Just remember this rule and make it easier for yourself.

Pick the lighter one and you shall be much happier, or it’s gonna be just a more predictable decision. Now one more announcement, my friends is with Protrusive, we’ve grown so much over the years, and I’m constantly looking to strive for better. How can we serve you better? How can we serve our community better?

How can we make learning more fun, more impactful, more actionable, easier to implement? And so some years ago, we introduced the Premium Notes. The revision PDF we have accompanying each episode as like a cheat sheet, a guide, an aid memoir, a quick reference to the main lessons that you picked up ’cause sometimes there’s so many lessons you might pick up in an episode and it’s difficult to implement.

But when you have it also in writing that you can highlight, it can follow along. It makes it easier for things to stick. But I’m pleased to announce that we’ve taken this to the next level. Now we now have a section called PITC. This is called Patient in the Chair. The best example of this is when you have a patient who’s had trauma in the chair, like an avulsion or something, what do we all do?

Even though we all kind of know what to do when there’s an avulsion, we still look at the guidelines ’cause we just want that quick reference and we wanna be sure that we’re doing the best thing. Now, anytime something is shared on the podcast, which is like really important, really worthy of a quick reference.

We are gonna put it right at the top, and we call it PITC. These are the one to three things in this podcast that you just need to know, and it makes it like a lovely quick reference. Oh, what’s that thing that Marco and Jaz said in that podcast? Now you’ll see it right at the top. You’ll also see that our Premium Notes are more visual than ever before.

And all the key takeaways summarize without any waffle. Think of that dental student that had the best notes at school, and everyone copied their notes is kind of like that. It’s like the revision notes of your favorite podcast episode. Now this is a paid feature, so if you’re on Protrusive Guidance, if you’re on a paid plan, you can access the Protrusive Vault, which has all of our infographics, all of our premium notes, all of our premium resources.

Every episode takes a team hundreds of hours to put together, including the PDF transcript, including this extra premium note with references and visuals. Now to celebrate the launch of this new style of premium note. I’m gonna give away this episode’s premium note for free. It’s a wonderful summary of everything that me and Marco discussed in this episode.

Complete with the visuals in case we’re listing on Spotify or Apple, and you want to see some of the visuals that before and after of how composites don’t look so good when you layer versus how good they can look when you injection mold. All the visuals stacked in there, any references that we think you might need, all the references that you should really read, all the key references, the key takeaways, the visuals that really add to the episode and enhance your learning.

Everything is there so you can download it for free as a taster, as a gift from Uncle Jaz to celebrate this upgrade that we’re doing. If you wanna get your hands on it, check out protrusive.co.uk/im just the two letters, right? Injection molding. protrusive.co.uk/im. If you are already watching this on Protrusive Guidance, don’t worry.

You don’t need to do that. You can just scroll down on the app and it is available under this episode as a download. But if you’re not on the app yet and you wanna check out this download really quickly, just head over to that site and you can download this news style premium notes for free. Let’s now catch Dr. Marco and I’ll catch you in the outro. 

Main Episode:
Dr. Marco Maiolino, my good friend, just every time I see your cases online, every time I see you come, I think of a wonderful time that we had at your course in Syracuse in Sicily. I still remember Granita, I still remember the culinary experience that you gave us. And if anyone wants to go on a hands-on course of Verti prep scene to check out Marco.

But another one of your passions, Marco, is injection molding, bioclear. And I really wanted to speak to you about these topics. Now, I’m gonna tell everyone to listen to our previous episode we did, the Imperfect Dentist. A good lesson you passed on is that if we strive to your perfect every day, we’ll be miserable.

And to aim for a consistent seven, eight out of 10 rather than three and 10 and three and 10, that kind of stuff. So just summarizing that episode. So I encourage everyone to listen to that. But Marco, just tell people who may be new dentists who haven’t seen your stuff. What do you stand for? Tell us about yourself, Marco.

[Marco]
Okay. It’s a pleasure to be here again, also because with just, we had the wonderful experience of being in the real life together because we did the vertical course, the real one, the three days course here in Sicily, and we’ve been enjoying a lot of time together. So this has been a huge pleasure to see Jaz in the real life and to see- 

[Jaz]
And even though Marco has no interest in football, he still took us by the seaside to see the match. 

[Marco]
Yeah. 

[Jaz]
I think it was Italy, Switzerland. I think Italy lost. It was sad. But you were in the sea, you were having fun. You were with your family and friends. It was nice actually. So. 

[Marco]
For me, the course is not just the course about speaking and doing something about dentists, something like about enjoying. The reason, because I do the course is a small course with just six, seven people is because I really want to do a real connection with each one, because sometimes I do bigger courses, not in my town, but abroad with 25, 35 person. But for me, and even for them, I think this is not absolutely the same thing.

The connection that you have when you are in few people. You go outside for a dinner, you go outside for the lunch, and you spend time joking about everything. It’s the time that you cannot compare with other kind of situations. About me, just because of course. I just want to introduce a little bit. I am a general dentist, a real general dentist.

I do almost everything in my office. Of course, I do also wisdom teeth. I do implantologists, I do implants, I do soft tissue, I do mucogingival surgery, I do everything. But of course, most of the people know me for two main things because I have something that it is a little bit more different to say, and it is about restorative dentistry, because in this field I have my own ideas.

And about prosthetic dentistry because I started working now 15 years ago with vertical preparations. And so I have 15 years of experience and follow up. So on these two fields, I have something more to say. When just came in Sicily apart, the Granita Granola Pizza and all the other incredible things that we do in Italy, we spent three days talking about relations, Arancini.

And also, I love reading. I am an obsessive reader. I read something like between 40 to 50 books every year and I love to read about psychology, management, all these kind of things. 

[Jaz]
So what are you reading right now, Marco? Tell us what you’re reading right now. What’s the flavor of the month? 

[Marco]
Okay. In this month I’m reading a book from [inaudible]. He is one of the most famous anti-aging doctors that we [have] in Italy, because I am very well into these kind of things. I know cold shower, sports, fitness, nutrition, and all these kind of things. I am very well to these kind of things because I have to work at least until my 85 years old. I have to see all the other doctors in the coffin and I will gain in that way with my handpiece working on the, this is the plan.

After I am reading on another book that it is Martin Jan Stransky,. It’s about the collapse of our mind. It’s a book about how today, especially on children, the exposure that we have about social media, iPhones, these kind of things, it seems that our children are the first generation that are starting to have a sort of devolution in the last million of years.

We always went through an evolution, but this is that from this point on in this century, now we are doing a sort of devolution. So it’s something that is interesting about, it explains how the brain is working, all the psychology behind the brain and about what happens when, since you are very young, you expose yourself to social connections or social media connections. These are two completely different things. And I think that this will be also a challenge- 

[Jaz]
A real connection and a junk connection. 

[Marco]
Yes. We are living in a strange period. Like for example, just to say about the first topic. It’s a strange period because there is a lot of discussion about, for example, nutrition, about fitness, about all these things.

A lot of education of content. Yet the number of people with obesity is always rising. The number of people with diabetes is always rising. So there is a sort of mismatch between what we know and what we say and what really happens. And this is the same thing that happens in industry sometimes because we talk about that.

And this is also the reason because I’ve been lobbying the other episode about perfectionist, because sometimes this is the missing link. Because when there is a huge gap between what we say and what we do, it means that there is something that it is wrong about that. And what I want to do in my dentistry, in my life, this is me, you wrote me.

It is about closing the gap between these two things. This is reason because I’m not a perfectionist. I share my cases and I want to do perfect cases, but I am perfectly fine with doing good average cases because this is my real life. But when I am able to do an alignment between what I say and what I do, I think that this is the best example that you can give to people.

Honestly, because you can teach what you are. When you are teaching something that it is not your real everyday life, there is a gap and the message is wrong, in my opinion. This is the reason, because I have not very good relation with several speakers because for them I’m doing slightly more than average dentistry.

But for me, they’re doing something that’s different, that it is just a sort of cinema, because it’s easy to bring five cases in the near and to bring five perfect cases when you have the possibility to choose the patient, choose the case, choose the time. Because if you take five hours for doing two empty restoration, okay, of course you’ll be able to do to great restoration, but this is something that it is not real.

Also, the obsession that we have about photography. Okay, I cannot talk, I mean, I have bouncer, I have here, I have everything. But there is a huge difference about the approach because something is to consider the documentation in the real value that it is to follow up cases. I did this 10 years ago. Let’s say what happens now, and this is what today, for example, we share, because sometimes I joke about I am a layering survivor.

[Jaz]
You’re layering what, sorry? 

[Marco]
Survivor. 

[Jaz]
Okay. 

[Marco]
To survive. 

[Jaz]
You survive layering. 

[Marco]
Survive. Perfect. Yes. Because my follow up on layering, for example, is not that great at seven, 18 years and it is something that I saw on a constant basis. It said my follow up injection molding that it is the main topic that we are going to discuss today, and this is also something that I’m going to organize something, you know in Milan at the end of the year is because I saw result that are less statistic.

Of course we are talking about a more concrete dentistry, but the result is much more stable over years. And I’m much more interested in the long-term follow up than on doing the artist day zero. When you do just the fourth at the end of the work and nobody knows what happens after five years, seven or even 10 years.

Most of our patients are much more connected with the long-term result and for the result that they are able to perceive. Because honestly, I have never a complain about the lack of opalescence about an intensive milky on one mamelon. Never. I have complain about the shape. I have complained about the triangle.

I have a complain about the leg of in insiders. So there are things that are much more important if we want to talk about real dentistry. Real dentistry, I mean the dentistry that you need to be successful in the real life of your town. There is another dentistry that, it is the dentistry that we like to share instead of social media on congresses. But it’s like real life and cinema. I am much more for real life. I’m not the guy aiming for the cinema’s approach. It’s just me. 

[Jaz]
It’s what I love about you, Marco, is the word to describe. It would be authentic, authenticity is there and that’s so, so important in today’s world full of social media dentistry, and I love this fresh injection of authenticity.

Now, you mentioned about following up these cases and how people don’t actually care about the tiny little details is the bigger picture, which makes sense. And it’s like the Pareto principle, right? 80% of the magic comes from the 20%, the overall shape really, and how you finish it to a seamless transition.

And then with that you get 80% of the benefit and then you can follow that up long term with success. And that is the definition of success. Now, today’s episode I want to just cover ’cause there’s so many different ways we can approach the different ways that we can do an anterior composite buildup.

So what I wanted to present with you, maybe I thought this structure may be better, is that if I give you three to five real world examples, and if you suggest, okay, in this example my preferred technique is A, B, C, or D, and then you say, why. Now obviously there’s so many ways to do it, but people may be inspired or maybe they have, ah, okay, this makes sense.

So if we start with edge bonding, every time I post about edge bonding people in the US they say, I dunno what that means. What is edge bonding? Okay, so just to clarify guys, what we mean by edge bonding is the patient has finished aligners, the teeth are a little bit short, maybe they’ve had a bit of incisal wear and you are just lengthening the teeth without having to veneer the entire labial surface.

It’s just composite on the edges. Yes, you will do a transition, but in your edge bonding cases, Marco, what kind of techniques and tools do you like to follow and use? Is it freehand? Is it led by a wax up always? Is it led bioclear, whatever it could be? How do you like to do your edge bonding, let’s say after aligners?

[Marco]
Okay. The problem about edge bonding is that most of my cases about edge bonding are cases after orthodontics because the problem that I see is that when you have patients with some wear, with some fractures, there is 99%, unless there was a trauma, there is a problem of occlusion because my worst failures have been when I’ve been dealing with patients with worn dentitions and have been working just from canine to canine, doing an increase of the length doing veneers in these cases without changing the vertical dimension of occlusion.

So before, to talk about the technique about edge bonding, injection molding is about talking about little bit about occlusion and and I know that an occlusion you are one that it is very well into this kind of field. What I see is that because my experience is that you have never increase the overbite of a patient.

Especially if there is a patient with some parafunction or with some wear. So the main problem is to say, I do edge bonding when I have this kind of patient, but after orthodontics. So if there was, for example, a deep bite, I’m opening the bite and I’m opening a bite a lot, at that point I can edge bonding about edge bonding.

The same is about anterior restoration. The most important part, and I did this mistake despite of this just two days ago, is about the color of the tooth. Because we can do edge bonding, we can do parts restoration when we have easy shades. I mean, you take the Vita shade, A1, A2, A3, and you have the surface of the tooth that it is matching with that color.

In this way, doing just a little bit of bevel is very easy to do a nice transition, even if we have to remember always that composite is material, especially when we are going to do addition on dentine that you need certain amount of thickness. And this is another point that people doing layering many times in order to get a little bit more of transparency, they’re doing very thin restorations.

And when I was doing these thin restorations, the typical outcome after one or two years, that was a small chip of the incisal margin, the incisal margin, asked to be thick, big goes composite is not ceramic. David Clark, that many things, he has been a pioneer, says that composite has to be minimum two millimeters thick on incisal margin.

Of course. When you have two millimeter with two millimeter, of course you are going to struggle if you want to do all these special effects in the incisal term. But if you’re going to discuss about the long term longevity of this restoration, you are not able to match the result of David does because you know the problem is the approach in your dentistry.

You want to be the artist or you want to be the engineer. In this moment, I’m doing a new office. You remember when you were in Syracuse, in my office, every single week. I have a struggle between my architect that it is focused on the static of the office, and he said there is the engineer that it is focused on.

For example, said on the stability at 10, 15, 20 years of the office, the same problem we have in dentist. The problem is that in a villa, in an office, in a house, the aesthetic is very important. Instead in the dental office, how much is important, the aesthetic for the patient, because aesthetic for the patient is completely different from the aesthetic for the dentist.

There is a mismatch between these two things. So what I did in these years has been two find tune my aesthetic perception to the real one of the people that it is paying for the work. So most of the times monolithic restoration are more than enough for this patient and they reserve veneers for some of them, but just for some of these patient, fewer of our patients really needs the plus value of indirect ceramic veneers. 

Also, because there is a different biologic price. When I’m working with direct restoration, most of the times I can work in a very minimal approach or no prep approach when you’re doing veneers, that with veneers, there is the problem of the axis of insertion, and there is a huge biological price sometimes.

There is always this sort of legend about veneers that you can do. Always minimal veneers, no prep veneers. But in the reality, the cases that are ideal for no prep veneers or minimally invasive veneers are not so many. They are the exception. And when you are dealing with diastema or black triangles, the coverage for veneers in this cases is quite invasive because in order to manage the diastema or a black triangle, the preparation to arrive on the palatal side. 

And you have also to go in the sulcus, subgingivally because in order to shape the emergency profile. So I think that sometimes we complicate our life to we as dentists and to our patients more than we need. And the layering is something that in the last years I realized that most of the layering in the restorative dentistry is much more complication than something that helps us.

Especially because that I have some cases that I can show you. Okay, so for example, okay, in such cases when, for example, anterior restoration, this is restoration a case of with 10 years of follow up, what is interesting to see is what? I did the conventional restoration layering, in this case, after a conventional preparation with a small bevel, I did all the steps that we know and I did what? I placed two layers of dentine.

One layer in the parallel shell of enamel, another layer of enamel in the top, and they put some special effects. The result at the beginning of the work in 2014 was quite good, but if you see what happens after 10 years, it’s something that is unbelievable because this is something that I realized very well with David Clark, is what composite is a material with a strange behavior. 

If you see, now, I can show you, for example, if you see the surface that we have when we work with composite, just with the spot, just putting the composite in such a way, and you see instead the composite that we have with injection molding, it seems that you’re working with two very different materials.

With injection molding, you always get a surface that it is like glass, it’s shiny. There are zero bubbles, zero void, and zero porosity. When you’re working, say with your puddle, you always, this is my experience several times, even outside of the mouth, you know there also to collect cases, to do some documentation, you have always bubble void proposities, and the initial layer that you do there is a sort of transition between the layers that exposes the composite over time to water absorption and to accelerated edging. 

More layers you do, in my experience, more edging you will get on that restoration and I can show you several cases like the one we’ve been discussing now, several cases and up 10 years. The outcome is always poor. When I do the same instead of injection molding because I started injecting my cases in 2014, so now I am close to my 11 years follow up.

I can show you some cases if you want. The follow up at 10 years of this case with injection molding. They are very similar to the first year of work, so injection molding. 

[Jaz]
I think the lesson here is the way that you choose to handle composite has a significant bearing. You could use the same composite handled in two different ways and then- 

[Marco]
Yes, the same composite. This is the case that I did for example, in similar case, it’s very similar to the other one. On this incisor, there is a restoration always with, but injection molding, one layer. And if you see the follow up at 10 years, this is the 10 years follow up on two to 1.1. You see that the edging of the incisal area is almost zero. 

[Jaz]
So for those listening on the podcast, he showed a layered case, and Marco’s a very skilled, gifted dentist. And no offense, Marco, but that 10 year case looked like maybe a student had done it right at 10 years. And that’s done by a skilled practitioner. The injected case you showed, it looked flawless at 10 years. And so the comparison there is very stuck. 

[Marco]
Yes. This is another case just to say, it says, with a broken incisor of such a way, look, the difference that we can get. This is at one month. You see, I did the layering with three dentine. I did the primary anatomy, secondary anatomy. You can see everything here. I did the opalescence in the incisal third, but the look after 10 years, again, this is short, very short.

And the opacity that, the etching that you have in the composite is something that it is unbelievable. And if I do the same case with injection molding, instead the composite is able to preserve its optical and physical properties in completely different way. This is the reason because I said that I am a layering survival.

And because I stopped layering my cases now since many years because when you start to collect your follow ups, and this is the real value that we have in using every single day, our photographic machine, our camera is this, not using the bouncer to improve our cases just with proper lighting and transform a dental office in a photo studio with the papers bouncers five, this is craziness. 

Sometimes it seems that we lose what is the main point of our work. The main point of our work is not to the show. The show is just for the dentist. It’s something that, it’s very true. Sometimes I think, yes, sometimes we are the push from social media, from courses, congresses, where you raise the bar, but you raise the bar in a bit different direction.

It’s like, for example, I am passionate about fitness. But if you go on social media about fitness, you see just people with six packs, arms like this. But we all know how you can get this kind of body, and it is not just with training and nutrition. It’s adding other things that I don’t want to discuss, but you know that when you do that, I do fitness in order to be able to work at 85 years old just to say they are doing, just in order to have an aesthetic boost.

But after 10 years of that life, what is left me is fitness for longevity. Fitness for health. This is fitness just for aesthetic. It’s the same thing. And in dentist with social media. And also I am sad to say that the most of scientific association, the push is always in the bad direction. It’s always about the aesthetic. 

This is my feeling is that if you look at injection molding, another case with injection molding, this is the follow up at 10 years. This is two restoration on the distal part of the lateral and on the medial of canine. This is a patient that it is not a very good patient with is plaque. You see that the edging of the restoration is almost zero. Another patient with a very complicated case with subgingival margin, with very tough cases. But at six years, this is the follow up that we can get with injection molding. 

[Jaz]
So this is with the bioclear technique though, right? That would be a posterior bioclear, I imagine.

[Marco]
Yes. This is a posterior bioclear, but it is not about bioclear. The point is a one there is injection molding is a way to apply composite in your restorative workflow. At the beginning in 2014, I was doing injection molding also with metal matrices with the TOR matrices with saddle matrices. So injection, of course, with the metal matrices, we have to change a little bit because the polymerization is different, but injection molding is a technique.

How to apply composite? After is what is your restorative workflow, and here we can discuss about metal matrices, TOR VM Matrices, bioclear matrices. Of course, bioclear have been designed in order to take all the advantages of injection molding, but you can do injection molding also with other techniques, honestly.

So injection molding is a way to apply composite that for me is the best. If you have to work with the composite, of course, after we can discuss about the restorative strategies, because what is interesting is that nowadays we have several strategies because you can do injection molding with bioclear matrices.

And I am a Canadian leader about this technique, but there are several interesting techniques. There is the iVeneer technique of an Israeli guy  Itay Mishaeloff  did other kind of matrices that are very smart in the idea. I don’t know. Do you know  iVeneer ? 

[Jaz]
No. 

[Marco]
It’s another technique.  Itay Mishaeloff , This Israeli doctor did different veneers that are going to shape all the buccals of face. I have some video if you want. I don’t know if we lose something about people that will listen, but I have some video about this technique. However, it’s a matrix that it is covering the buccal wall and you are going to print with the ready premade matrix. All the buccals surface. So you have what? You have in your kit, you have matrices with whom. 

You can shape the buccal surface in a very good way using always an injection molding technique because the matrix as a whole where you can put your material, or like for example, Marco, because it would be the spear in the summit that I’m going to organize about this topic in November. He is doing what he is doing an impression of the patient.

They are also also [inaudible], you know, he is another speaker about this topic. They’re going to do what? They do an impression and you can do the impression digital or analog. You are doing the wax, again,  digital or analogic of the case. They are doing the silicone matrix with the transplant material and they’re using the silicone matrix with some holes in order to inject again the material.

So you see injection for me is the way to go, but how to inject is very interesting because all these techniques have pro and cons. And this is what a lot, because in the recent years we had an evolution of all these techniques and there is always a growing, a growing interest. And what a lot is that all these techniques are something that you have, you can use in your daily work, not just for doing the case.

Because nowadays in my dentistry, I hate to do the case. I mean, it’s nice. The case, but if your dentistry is focused on the case, there is something that it is wrong. My dentist is focused towards everyday dentistry. Sometimes I’m able to do the case, but it is not my main focus. 

[Jaz]
That one nice one. The unicorn one that comes along. That you get to have lots of fun, but you’re a real world dentist. Just so I can get the structure of this podcast, Marco, edge bonding. Okay, so you’ve discussed that injection molding as a way to deliver your composite has some advantages and I can see that compared to layering and what you’ve done is shown clear examples, follow ups whereby the injection molding looks superior.

At day 10 years, maybe on day one the layers maybe looks a bit nicer, a bit sexier, but at 10 years the injection molding technique is superior. But do you, after aligners to get a better occlusion, let’s say, do you utilize injection molding for edge bonding or do you think this is such a simple, direct free hand that you still use your paste and you try and do edge bonding without the injection molding technique?

[Marco]
Okay. I think that injection molding is mandatory for me. So what I do is we do watch bonding. I always want scaffold. Of course, when the case is easy, you can do the scaffold also with transplants matrices or something like that. But the problem is one, for me, free-hand there is not the pressure that we need in order to put the composite in the best situation to perform.

So I never take material with a spatula and they put some work. So if I have to do edge bonding, what I do, I want always to have some matrices. In easy cases, I put varistrip, for example. You know the blue transparent matrices, they are very easy. I put that by Garrison. So that I do what?

I always want to have David Clark talks about adding an aquarium, a chamber, a place where you can inject with some pressure, heated material. So what we do in all my cases, small restoration, big restoration, I always want to add something like a chamber and aquarium where I can inject. Of course, in the simple cases, this, most of the design means to have maybe just a  varistrip matrix just wrapped around the tooth or in the rounded area, and maybe I just stabilize with some teflon, some liquid dam or with some flowable in order to have, but I always try to do a small chamber also, because when you start to be in this kind of rationality to put a matrix and build something that it is like a small chamber, it’s something that you need 20, 30 seconds.

I do even class five in this way, for example. See, I have a technique about doing class five because doing class five, for example, is the same problem with class five. I was doing the action with Teflon and I was applying with my spot, but there was feeling that after seven years I was seeing that the follow ups on class five, it was not the same of restoration made with injection because when I was applying with my spatula, I was missing the pressure of the composite in order to put the composite in the best situation.

Now instead, I have a technique, a very easy one, where I use an automatrix or unica matrices, but I always build a scaffold where to inject my composite. This is my way to go nowadays in all my restorative work. And it is something that you can do in your everyday cases because to put thematic in that way, one minute, one and a half, it’s something that I’m not discussing about two hours appointment, three hours appointment.

If I see my scheduling nowadays here in the office and I’m working, most of my scheduling is based on one hour, 75 minutes appointment. I have not long appointments in order to show my artistry. I am a very basic dentist, but I do something when I say that this thing works every single day in very good way on the long term. And for me- 

[Jaz]
What I like about you, Marco, is when you talk about a technique and it’s a bit like, you know, at one stage you are enjoying your layering, you’re doing this, but what you do is you’re not afraid to look at your own work and say, hey, you know what? We can do better. I need to change something.

And then you can put your hand up and say, I was wrong. I was wrong to do it that way. I think this is the best way. And maybe in 10 years you’ll refine that even more, and something new might come out. And it’s important to be open to change. And that’s something attractive to do is being keep your mind open that hey, you know, this is working, but I’m willing to change if something better comes along.

And so far, I am injecting in some cases, like anterior wear, we’ll discuss that. But for class fives, sometimes I inject, sometimes I do freehand with like PTFE retraction. And I agree. Once you get that scaffolding, I love that the aquarium, the chamber, the scaffolding. It just makes so much sense.

I’m surprised you actually said about edge bonding. I’m glad you mentioned it, that you are so convinced and dedicated to the injection molding way to deliver a restoration, that you’ve pretty much now found ways as long as you can make your scaffold, you can inject. So I’m imagining you now, when you’re doing edge bonding, you used a various strip, for example, you create your scaffold, you inject in now just tiny geeky details that dentist love.

Do you like use a tiny drop of a flow and then you like a snowplow technique and then put your heated composite like that? And what’s your preferred composite of choice for let’s say edge bonding? 

[Marco]
Okay. During monolithic restoration, the other good part that my assistant, the assistant that it is working for the storage is very happy, is that I reduced the heavy way, the storage composite.

Because if you see my office, I have just three comp, I have A1, A2, A3, and I have a bleach. And it’s easy in this way to manage because the problem is that if a tooth has a strange color for me, what I have to do is to cover all the surface. It’s much easier because too much your composite shades with the French colors, like you know when you have a sort of orange, a sort of brown, it’s MS, I saw on the book layers of the group that they start to combine a little bit of A2 shade with a little bit of brown, super thin, super core in order to create another. This is not everyday dentistry that you can practice also, because when you have to mix in a different way for every single case, it means that there is a question mark everywhere.

Instead, I want my dentist to be fast, reliable, predictable. When you have strange colors for me, you have to go over the bucket surface. Most of the times it’s much easier to get a good result and all the patients also love the aesthetic result when you’re doing that. So you have something that patients love. 

Doing injection molding, I have ecosystem result under long term and it’s very easy for you also to manage, so you have not to get crazy about matching the color, the composite to a strange substrate to a strange color. You do the opposite. You go over that and you close. 

[Jaz]
The shade system just makes so much sense in terms of simplifying, and this is why your team now loves you even more because of this simplification there. Is there a composite that you found to have superior longevity in terms of color stability, polishability?  Is it a 3M Filtek? Is it Estelite? I dunno, what are you preferring nowadays? 

[Marco]
Okay. What do I use every single day in my life is I use 3M materials that they are no more 3M, but because they did a change. Now 3M became Solventum and I’m also speaker for them. But between all the materials that 3M is doing, I use for all the cases, whether I want aesthetic, both anterior and posterior. I always use supreme material. I know that supreme is not the newest material that 3M did. Even if there is the technology, it’s always nanoparticles.

This kind of technology, but supreme in both posterior and anterior cases in my hands, gave very stable results over time. So what I use is I use supreme flowable always after warming the material. I put a little bit of flowable. I don’t use the light lump at this stage. And after I inject again, warm composite, the heat that I have is bringing the composite to 70 degrees Celsius. I don’t know in Fahrenheit how many degrees these are, but I warm a lot of the material, especially because supreme is a little bit viscous material. 

[Jaz]
Is it stiff? 

[Marco]
Yes, it is deep. So I warm a lot, but I love the aesthetic result and the consistency and also the how you are able to polish this material. Instead, for example, there is for people with a heater that it is not so strong. There is, for example, the universal restorative is much more creamy. So it’s enough to do just a little bit of warming and the material is already flowing everywhere because injection molding is also, for me, the only way in which you can manage claustrophobic restorations.

Interjection:
Hey guys, it is Jaz with an interjection. So firstly, thank you so much for approving the interjections. I did it for the first time on the Lukasz Lassman episode. We did occlusion miss and red flags just a few weeks ago. And sometimes what happens that the guest is on a roll. But I’ve got so many questions in my mind and the guest is going for it.

And so I kind of hold back, but I know that I want to talk about something ’cause I do feel to make something more tangible, it just deserves us to go slightly down this rabbit hole just to explain something or to put some more clarity on something. And I’d asked you to write in the comments what you thought about the interjections.

And thank you, Joyaffif, Emily, Joseph, Barbara, so many of you said, and the interjections are good and approved, so they are here to stay. So the first interject one of two for this episode is just heated composite. I think it deserves just a few words. Many of us are already using heated composite, but if you’re not using heated composite, you might be thinking, what’s the point?

Why would you use a heated composite? If you want it to flow more, why not just use a flowable? And I get that. But a flowable is different to a paste composite. A paste composite has a much higher percentage of filler particles. It is categorically a stronger and a mechanically superior composite to a flowable.

And yes, the number one reason why I use heated composite is ’cause I don’t like working with stiff composites. I like them to go a little bit soft. It just makes handling better for me. And adaptation as you are dispensing that heated composite from the compule into the cavity, for example, it’s just smoother.

And the way that that composite adapts to the cavity walls, it’s more seamless. It just flows better overall. So it’s the handling that I love the most about it. Typically speaking, composite is heated to 55, 60 and Marco is 70 degrees. I also do about 65 to 70 degrees Celsius. All that kind of range is totally fine and sometimes if you’re using something like Estelite, which is a softer composite, you probably wanna go for that 55 degree region.

But if you have a stiffer composite, like I use a lot of Venus really enjoying Venus Pure at the moment for my aesthetic work, and that is a stiffer composite, so I like to go to 70 for that. Again, for me, a big part of it is improving the way the composite handles in my hands. When you look at the literature resoundingly, it’s mostly good stuff when it comes to heating composite.

It does not negatively affect the strength. In fact, it actually improves the flexural strength in some studies and you get a higher degree of monomer conversion. So is there any bad stuff out there? Well, some studies say that repeated preheating cycles have a detrimental effect on color stability of composite resin.

So basically the takeaway here and what the manufacturers are saying as well, is to use the small compules when you’re heating. ‘Cause when you use it, it’s done. You throw it first to those large composite tubes, then the manufacturers are saying, look, it’s probably not a great idea to heat. And allow that to cool.

And then heat again and allow that to cool. And listen, if you’ve been doing this, don’t worry. I’m just saying it’s one of those things that we just don’t have enough data for. Like definitely a bad thing, I don’t think. But it’s just much safer to be heating the small compules than to heat the entire slab, the entire tube of composite that might be going for several months constantly heating, cooling, heating, cooling.

And in my mind, yeah, that could potentially have an issue, but I at the moment use compules have doing so for years and I’ll continue to, because I love using heated composite and from the literature that I’m reading, it’s totally okay to do. Just one more little nugget is that yes, you heat the composite, but it cools really fast, so don’t worry about you thinking that you’re gonna cause the tooth to burn and the pulp to burn.

Usually we have enough remaining dentine thickness. It’s really not gonna be an issue. And also as soon as you take that composite out of the heater, it’s gonna rapidly cool. This is why I sometimes will actually heat my metal instrument as well to just prevent it cooling so quickly. So heated composite. Big thumbs up. Crack on guys, let’s get back to Marco. 

[Marco]
Like for example, do you see this case just to say? 

[Jaz]
Yes. 

[Marco]
Okay. For example, when you have a claustrophobic restoration, like for example when you have, let’s say less than one milimeter diastema, that you put your matrices and you have two restoration of three 0.4 millimeters. How you can be reliable about being able to layer and bring composite to go around the tooth and behind the shoulder of the tooth when the space is just 0.3, 0.4? Or when you are doing, for example, a small black triangles and you are dealing with 0.5 millimeters restoration, very close to the gingival margin.

Injection molding also is the only way in which you can be reliable about getting this kind of restoration in a very smooth way. And this is the follow up of the cases that you can get. You see when you are starting, like in a case that I’m showing with a normal color of the teeth, you can do just the restoration of the diastema or of the black triangle without any kind of problem.

Honestly, composite here is supreme. Composite is very biomimetic material. It is very mimetic, but when you are dealing a study with the fit with strange colors, I did a mistake last day. There was a patient, and I’m going to post this case in the next days. I have the appointment Monday. And after I will fix my mistake because the main mistake was on my side.

I will post the case. There was a patient coming in my office for black triangle after orthodontics, but there was in the third medium of the center incisors. This was a sort of brownish area, not so much. I told to the patient about this area and you told me, okay, I never realized this, but this is not, has never been a problem.

I’m coming from black triangles. The problem must be that when I did black triangles, and so you have on the mesial and distal, you have some composite with just one shade. Now, this brown area is much more evident than before. So the patient completed the appointment saying, I am very happy. I have no more black triangles.

I am very happy. But we called back again saying that the brown area that he never noticed before, now it was more evident. It was much more important. So he asking me to solve again this issue. So Monday I will go back in this case. So the diagnosis of the case, for example, about all the edge bonding, what is the reason behind the chipping and the fracture?

It’s the occlusion. And what do you have to do many times orthodontics or when you’re going, for example, with patient with worn dentition. It’s about because of abrasion or it’s about erosion. These are two complete different situations with a complete different solutions because on patients with erosion, as long as they have enamel, a sufficient amount of enamel, I am always successful regardless.

We can say with the occlusion, okay, not, but it’s less important occlusion. But when you’re doing a steady patient with the  worn dentition because of occlusal problem, if you are going to do, for example, an important canine guidance, an important incisal guidance, they’re going to break everything after a while.

So there is much more that we have to discuss about why the patient is in that situation before doing the treatment. And this is something that honestly we can understand, just sharing our failures, because many times the failure is not in the technical part, but the failure is something in the diagnostic part.

But the failure is coming after three failures. For example, I have not a great outcome with very compromised teeth with fiber posts. Okay? But most of my failures are after six years. Most of my failures with fiber posts in compromised case, we scarce failure are between six and nine years. So the problem is that how many times do you follow up your patients for six, nine years and you start to collect all the first that you have?

Few are doing this because if you see on social media, on congresses, you always see short term follow up most of the times. Like for example, with shoulder, we know and there is something that you find out some papers that soft tissues on shoulders are easier to get recessions. Easier to get recession.

Instead with vertical, it marked more easier to avoid the recession, but in the past you were never able to discuss this because people was not going to show 10 years cases with horizontal, with recession of courses and congresses. They were showing all the artists of the technician at the 10 0 6 months and after they were going to the next case.

We have a disease about showing our best. Instead, what would be interesting would be showing what is not going to work. I understand that people, that it is starting to introduce themself in this world. They want to show their best because I did the same, honest when I started 12 years ago, to be a speaker, to speak to lecture, I was doing the same.

I have to be honest. But after a while, I think that it is the responsibility of those that already showed that they are good dentists to show what is not working. I think that I can forgive easily people that is starting now. If you’re starting now lecturing, you have to show your best because you have to show the people that you’re good dentists.

But after 10 years, I think that it is your responsibility to show your best, but even what is not working, because I’ve been learning much more from my failures than from my best cases. 

[Jaz]
One of the best lectures that you do, Marco, as you know, is in your course in Sicily the last few hours dedicated to all the failures and lessons, and that’s always very special. Shout out to Costas Koleonidis, who currently I believe is a Greek dentist in Switzerland, who’s one of your alumni as well. That’s right. Before I went to Sicily, he told me, watch out for this one lecture. Watch out for this one lecture.

And I can say it’s so lovely. When people share their failures and mistakes. And open like an open book to everyone. So appreciation for that for sure. Now we discussed edge bonding and you’ve convinced me that yes, the way to deliver the composite to not get so much air is perhaps not with the spatula to make the scaffold.

I love the scaffold. The chamber, the aquarium. That makes sense. You mentioned composite veneers with that technology. Now, just for the interest of time, black triangle closure is kind of like that claustrophobic area and you use an injection molding just makes so much sense and something like Bioclear is amazing for that.

Some colleagues are using metal matrices and they burnish them out and then they create their scaffold. So there are many ways that you can create your scaffold, not just the bioclear, but the thing is, as long as you then create the scaffold and then you’re able to inject into it and place into it, it makes a lot of sense. 

When we think of injection molding, Marco, most colleagues are thinking of using the genial injectable gold one into a clear stent like Exaclear that, usually we think of that as the injection molding, but you are right. All the other applications we discussed are the method or the technique of injection molding. How often are you using this technique as your favorite technique for managing tooth wear?

Either erosive attritive, or usually combined erosion and attrition. What are your thoughts on the exaclear technique with the GC composite? 

[Marco]
Okay. The problem, I use this technique, but in my practice I work something like 80% to 90%. I work with the Bioclear and 10% to 15%. I work with this technique with Exaclear, the main point is what?

The problem is, the inter proximal control. When you do this kind of technique, there is a huge problem about the interproximal areas. So if I have a patient with no black triangles or very small black triangles that I’m going to keep putting little bit of Teflon, and so the biggest problem is on erosion of the buccal wall or abrasion of the palatal wall.

I’m doing what I am doing the waxing with my technician being zero point something short under the proximal wall so that I’m printing my composite on the buccal or on the palatal and incisal. But I’m going to do zero invasion on the proximal wall because when you are trying to do, in my opinion, when you are trying to close something like a diastema or even worse like triangle with this technique, the problem is that after you have to spend a lot of time about finishing inter proximal areas, the problem is what that in the photos, I have to be honest in the photos.

It seems that you’re able to get a decent result, but honestly when I see with air drying the restorations with magnification and I see the interproximal surfaces in comparison to the surface that I have with injection molding with matrices is surface is — honestly. So the problem is when you are doing with these cases, what is the critical part of the restoration?

The buccal wall, you can do the exaclear. Palatal wall, you can do the same, but when there is a huge interest in shaping the interproximal wall and especially the inter proximately the subgingival wall, at this point I’m starting to maybe start on other techniques. So it’s about the involvement of the interproximal area.

The most important part that is driving me towards the decision between the Dahl technique, maybe with bioclear matrices or the injection technique. This is the most important part, the control that you have. There is also the problem that we are discussing about occlusion, because again, I never increased the bite.

So most of my cases are cases with the increase of the vertical dimension. And there is, I think also something that in UK I think that you’re doing a lot. But in the rest of Europe studies less used is the DAHL approach. DAHL approach is a very smart technique because most of the times we have rise the vertical dimension.

But economically speaking and technically speaking, it’s completely different. The work, if you have just work from canine to canine and after, wait for the extrusion of the posterior teeth and instead if you have to place also overlay on premolar, premolar, molar and molar, the cost is almost doubled because from six tip you are moving to 12 tip.

So there is also this, even on this topic, there are other interesting considerations that I never heard about because I had what doing DAHL approach you have to be careful about. One thing, there are people with atypical swallowing. Most of the times when we talk about atypical swallowing, we always talk about the anterior open bite. There is these people pushing the, what is the name? 

[Jaz]
Tongue thrust. 

[Marco]
Okay. They do that. And you have open bite. And so it’s easy for most of the practitioner to understand that with the tongue thrust, you have open bite that you’re able to close. But there are other people that have another kind of atypical swallowing.

They put the tongue or the posterior tip doing something. They are in the age of development. They develop a sort of deep bite because the tongue is keeping the molar in the position and you have the extrusion of the lower incisors. But if you’re going to do the DAHL approach on this patient and you’re opening a little bit more that the tongue is able to come, right, that position.

Interjection:
Hey guys, it’s Jaz again with the second and last interjection for this episode. So Marco just mentioned something really interesting, right? Typical versus atypical swallowing. It’s actually a really interesting thing and a really important thing that often gets overlooked. Normal or typical swallowing.

What we do with our tongue is we rest it behind the upper incisor, so in the incisive papilla region and the teeth are able to come together usually in your normal bite, AKA maximum intercuspal position. So teeth come together, usually lightly, and then we can continue with the swallowing reflex. The fact that the teeth are now together, it kind of stabilizes the jaw to allow you to swallow.

And it’s important to stabilize the mandible because if you try and swallow with your mouth open, just try it for a second, right? Keep your teeth apart and just try and swallow. See, it’s much more difficult. You need your mandible to be stabilized. Hence why one of the functions of teeth is to help with swallowing anyway.

So that’s a normal swallow in atypical swallowing, which usually happens in kids, and they grow out of it by age nine onwards. And what the tongue can do can actually do many things, right? The classic one is like the anterior tongue thrust. And so now instead of the teeth biting together, there’s your tongue in the way.

You’re kind of biting on your tongue and then swallowing. So your tongue is being used to stabilize your jaw. And what Marco’s saying is that there’s a variant of this tongue swallow whereby tongue is like spreading laterally and it makes sense ’cause I think we might have all seen patients with these like posterior open bites and you’re thinking, why are these teeth not settling back into occlusion?

Well, how can they? If every time the patient swallows the tongue comes in the way and stops the teeth from meeting together. And so it makes sense that if you open the vertical dimension on these patients and you do a DAHL type treatment, if they do have an atypical swallowing, that this will interfere with the dental alveolar compensation eruption.

Call it what you want. And actually the tongue, we know the tongue is the strongest muscle in the body. And I see some patients in my career so far who have destroyed fixed retainers, i.e. These metal fixed retainers typically bonded to the palatals of their upper incisors, right? So it’s upper fixed retainer.

They just snap, snap right in half and their teeth start to splay because of this all mighty tongue and this atypical tongue swallowing. So if you see something strange going on, have a look at their swallowing again. Once again, let me know, guys, are you enjoying these interjections? I’m happy to continue them. I love doing them. I learn a lot and I love to share it. Thanks for listening to far. Let’s continue your almost to the end. 

[Marco]
These are the cases where I had huge failures about doing a DAHL approach and keeping the posterior open bite without end, we can say. So but again, talking about failures, this is the main point because it’s easy to say, do DAHL approach and it’ll extrude.

Yes. But what if they don’t? Because this happens. And why? Because if you’re able to understand, sometimes it happens, but there is a reason you can select the cases. Cases selection is the most important part of our work. The patient has parafunction. The patient has erosion, the patient has abrasion.

The patient has strong thrust the patient that there is enamel or not. Because even on adhesion, I get aggressive. I’m doing mainly adhesive dentistry, but adhesion is not the religion. For some people it seems that addition is a religion. They do adhesion everywhere. You see teeth with zero enamel and chronic sclerotic, dentine, and they are doing adhesion.

Adhesion is not the answer to all the problems that we have. Sometimes we replace things that work, like for example, a cuspal that sometimes is the best solution with things that seems more modern is the difference between science and scientist. Science is science and we know. But scientist means just because something is more technological, we think that it is better.

There are a lot of wrong messages that you are exposed every single day. Like for example, rubber dam, I use rubber dam, you see my cases, and there is always the rubber dam, but sometimes rubber dam became a sort of indicator of quality of dentist. You are not accepted in a scientific society unless you put the burden in a graphically perfect way. 

So there is something that was born for a news and we have to say when the dentist that started using the rubber dam started, you know what the reason they were working with amalgam, there was no suction available. That was the reason because there was suction available.

When suction was available, they immediately discarded rubber dam immediately. So when they say they were smart because they started working with rubber dam 150 years ago, they were not smart. They had no suction because when suction arrived at the beginning, it was much easier to work with suction after of course with composite hydrophobic materials adhesive that are not friendly with saliva is rubber dam again became useful.

But again, from something that is useful to something that became mark of excellence, there is something that it is missing between these two things because you can do excellent dentist, for example, without rubber dam. I do most of my class five, for example, in class five, placing the rubber dam sometimes is a mess. It’s much easier and reliable and predictable to do a class five sometimes without the rubber dam. 

[Jaz]
But I agree. Rubber dam is helping you and then use it if there’s a tongue in the way, if there’s a tricky scenario. But if rubber dam is hindering you and making your access more difficult, then why bother?

[Marco]
Yes. The problem is that when you are exposed to courses in congresses, all the speakers say that they play rubber dam in 100% of cases. They say that the rubber dam is mandatory for the success. I know that we humans don’t like uncertainties, so we like strong messages. The point is that sometimes these strong messages are leading in a very wrong direction.

So if we were able to share more our failures and problems, this would be a very good way to improve our life. The life also of most of the majority of dentists, because they are exposed to very different messages. 

[Jaz]
We can’t be dogmatic about anything. Yeah, it’s a key lesson there. Marco, as we wrap up, we’ve got a few questions in that scenario with generalized wear. I’m just trying to visualize it makes sense about the interproximal success you get by using something like a bioclear, right? Because I agree when you use the Exaclear stent and how messy, even if you use the every other tooth there is finishing to do. And I agree that under magnification and when you dry it, it’s a surface that leaves much more to be desired.

I agree with you. But when we have to add material to the palatal surface and we want to be guided and directed by a wax up, by a planning, how do you do that with bioclear? Do you make a scaffold palatally first and then do the bioclear? Or how can you do that part? 

[Marco]
Yes, because the nice part is what, because if you start to be much more horizontal, I say about our techniques, you see that the indication, like for example, if I have a patient with a lot of palatal wear, let’s say, and then black triangles, why not to do just let’s say an index for the palatal wall without the embedding interproximal space?

And so you do the injection of the palatal wall so that you have right vertical dimension, you have the right anatomy of the syndrome because this is extremely challenging you to do the right anatomy of the palatal part, the free end, and after you can work instead on the black triangles and the buccal surface, maybe with a direct approach or sometimes you have, for example, in the posterior you can work with injection for example.

I have a case that I have to do by two weeks and I will do injection with the Exaclear in the posterior teeth because there is a problem of loss of vertical dimension plus erosion. This is a patient with erosion. So I’m going to increase the vertical dimension, injecting like table top, the posterior with composite, and after I will do just bioclear instead on the anterior, this is the case of a lower arch, and I will do from canine two canine, I will do just Bioclear.

If we are a little bit more flexible, we can combine and take the best of this approach. Even the other approach, I have to start with the technique of Itay, but I think that also the technique of Itay, iVeneer, there is something that it is very interesting and smart about this technique. So the best is to master different things so that you can mix all of them in order to fit the case.

Because if you want for a man, if you give to a man and a hammer, everything will be something that has to crash, you know? Instead, if we have several horrors in our work. We can use the best for each case. Also, because again, now we are discussing about composite, but you know that I am also a speaker about [inaudbile], so prosthetic dentistry, so the decision is even before when ceramic and when composite.

So the topic is even, there are even more nuances about this topic. But again, the decade is well show your case with ceramic and the failures that you have show the case with composite and the failures that you have. There are problems about the technique or there are problem about the choice of the material.

Again, we have to discuss failures, but this is something that I find extremely challenging. Now for example, with the summit that I’m organizing in November, I am quite picky about all this speakers about, show some problems, show some problems. I don’t want. Sure you have. 

[Jaz]
It can’t just all be fairies and rainbows. You gotta show your struggle. You gotta show. I am asking, I knew when you were organizing a conference that you would bring this ethos and make sure that people have this on board. 

[Marco]
The conference that I’m organizing is because it’s not for economical reasons, because I’m mainly recollecting expenses, but it’s because I want to give a message. The message is what I’m discussing in this podcast with you. But the point is that I have to make that all the speakers more or less because of course they are not like me. But more or less, each one of them has to deliver some problems why these things happened and now they have been solving this. Otherwise it would be just again, another show. So it’s about- 

[Jaz]
Tell us more, my friend. Remind us of the date. And it’s in Milan, right? So tell us, because this sounds amazing. I mean, I had a look at the date personally due to family reasons I can’t attend, but it looks amazing. You got some brilliant speakers. I mean, you mentioned Veneziani, Sakowski, our good friend, Johan Hagman, what a great dentist he is. Yeah, lovely guy as well. You got a great list. 

[Marco]
Okay, this is the summit about, because there has been an expansion and the growth of all these techniques about injecting composite, I start to think about doing a different event, doing a sort of point of the situation, collecting all the different techniques we will get David Clark, of course, is the founder of Bioclear and he is a man with several interesting insights. 

So is a math that David is coming. After we have José Roberto Moura. José Roberto Moura is a Brazilian. He is an excellent dentistry and he’s combining in his practice injection molding plus layering and is combined these two techniques.

Also, it’s nice because José Roberto Moura is working always with microscopes, so we will see a lot of videos and so we have a very good perception of his work. Ronaldo Hirata is a very famous Brazilian dentist. I don’t know if you know Ronaldo. 

[Jaz]
Yes, yes, I’ve seen him. He was very well known. International speaker. Absolutely. 

[Marco]
Yes. Ronaldo is a very famous speaker and he will come in Milan and showing, even in his case, because is working both with injection molding and is working also with layering. So it could be nice to see how to manage all the indications for different things. It that it is the speaker next to me is instead the inventor of I veer matrices.

So he will show this other approach if you want to have a small video about this technique. But the problem is that for people just listening this episode, however, these are matrices that are covered. 

[Jaz]
I’ll put it at the end of the video. For those who are watching, they can stick around and watch that actually, yeah.

[Marco]
Okay. After we have Marco, Marco is one of the most renowned I speakers. Marco is doing excellence in the dentistry. He is working with the index technique, the Exaclear, but he has his own protocol because he did some modifications in order to improve all the workflow. And this is something that he will be able to show in our summit.

Albar is doing something that they love. Alvaro will show just cases with minimum five years of follow up composite restorations made with different techniques. What happens after five years? So love it. Alvar. We will sue the truth about composite, and this is something that I will really love after we have another speaker that it is Abdurahman. Abdurahman is a Egyptian speaker. He very close friend of mine. 

[Jaz]
The Prince of Egypt, I call him. 

[Marco]
Yes, yes, he is. He is. He’s the prince of Egypt and we will talk about his, that treat situations that we never discussed and it is how to manage composite restoration close to implants. And this is some, because there are several complications because when we have decay or other problems close to implants, usually decay is more cervical than usual.

There is the problem of the separation. So we will discuss about all the restorative strategies that he has been looking for in these years about how to manage these tricky situations. With John, we’ll discuss a evergreen topic, especially in real world dentistry that it is subgingival margins because this is an evergreen topic. 

With Matt. You want know is that this is the French print. We can say, Matthew is interesting because he started working with the printed composite because the printer in his office and he will discuss the difference between working with printed composite and direct approach about time efficiency. So I am not the printer in my office, but when you start discussing about being efficient and being productive, it is something that for me is very an actual topic.

And after we will get workshop so people will be able in classes of 20 persons to touch together with upper and tadi, she’s a Biore speaker from the south of US and Claire Vargas that it is the Biore speaker for UK. 

[Jaz]
UK. Woo. 

[Marco]
Yes. UK. Yes, Vargas is the bio center in UK. People will be able and together with also Marco Ani for their technique. So we have three tutors. We’ll be able to organize workshops so that people at a very low price because we are discussing something like 100 euro for two hours. 

[Jaz]
Oh wow. 

[Marco]
Two and a half hours workshop. We’ll be able to touch with their hands, the material, and so to feel what is injection molding, what is to inject on Exaclear. They will be able to touch with their hand. Everything in the wonderful place of Milan that the problem in Milan is just the amount of mind that you’re able to spend going outside and will do also gala dinner will do also some social activity because again, it’s something that- 

[Jaz]
Wish me luck. I know I have some family commitments, but I’m gonna do it. I’m looking these speakers again and just how excited you got me about injection molding and why I realized, okay, I need to be doing more of this. I’m gonna ask my wife today to see if I can get her blessing level one permission. So wish me luck. But you missed the most important speaker, Marco, as well as yourself. You missed the loveliest person, honestly. Just absolute sweetheart of Aara Aara. 

[Marco]
Yes. AP is the tutor and she will be the tutor of the Biore approach. We’ll do anterior restoration. 

[Jaz]
She doesn’t drink alcohol. But she came to your course in Sicily and she brought everyone a bottle of rum, right? And she’s just the loveliest person you’ll ever meet. And I’m always a big fan of not only going to the educators that inspire and show excellence, but their human side. They are beautiful inside as well. Right. And so I’m just very, you, it’d be nice to connect with Aara. So wish me luck. I’m gonna ask my wife if I can get a day off seventh and 8th of November, 2025.

[Marco]
Two things, just because this point I have to say something more aara together with me, the one that will manage all the speakers will be the, I don’t know, master of ceremonies is something that you say. 

[Jaz]
Okay, MCs nice. 

[Marco]
Okay. She will help me on the stage, introduce the speakers. Because what we want to do is something that it is new. Nobody will come on the stage talking about their curriculum. I will never say, here is doctor Jaz Gulati, got his degree. Nothing. Everything would be about the person, the approach, the philosophy. We want to do something. It is fresh. And also, there is a dentist coming from US, Joshua Sullivan. He is a very, a famous pediatric dentist. And he was nice because he told me, I went home like you say, and I said to my wife, look, I would like to go to another congress. And she said, no, another Congress, no. But where is in Milan? Whatcha waiting for tickets? So this is another reason that it is. Yes, yes, yes. It was- 

[Jaz]
Maybe a weekend away I might arrange some childcare for the boys and I’ll whisk my wife away for a romantic weekend in Milana. And she’s a dentist, she’s a pediatric based dentist. But you know, I can tell her, you can learn something for your patients. In fact, I think it’ll be good for her. 

[Marco]
Yeah, also, because Milan is a very nice place. Also, the venue is called Grand is five minutes using the subway from the center. So we are in a strategic place also for a holiday. So I think that it is. 

[Jaz]
This is gonna help a lot. 

[Marco]
Yes, a good situation in order to connect a little bit of education and a little bit of fun because we spend a lot of time together. And also the possibility to visit Italy because Italy is Italy. 

[Jaz]
It was my first time at your course in Italy actually insisted my first time in Italy. I’m just, the food was just, everything was good and for those of you listening on Spotify and Apple and stuff, one thing you missed is the hands gestures that Marco like, it is true. Italians speak with their hands. It was very evident for those who are watching the video. Now I’m gonna put the links and everything in the show notes so people can check out injectionsummit.eu is the website.

And fingers crossed me and my wife will be able to come. If not me and my wife, then hopefully just me. Either way, I just really wanna come. So pray for me guys. Now one thing, unrelated a little bit, I just want your opinion, Marco, right, you must have seen on social media, right? Marshall Hanson in US is doing incredible work. Have you seen his work online? 

[Marco]
No. What is the name? 

[Jaz]
Marshall Hansen, he created the home of the 48 hour Smile makeover. So essentially what he does is, and I hope I’m not perversing this right, but essentially what he does is he brings one patient and he keeps him in his office for two days, basically.

Okay. And in two days they will leave with composite makeover, which is just phenomenal, I believe the way he does it, he’s the first day he just builds the shells, builds the base, okay? And maybe he’s doing some injection molding type technique. He’s using the Garrison Strip and whatnot and using these special matrices and he’s building the base all in monolithic, I believe.

Okay. If I haven’t got this wrong. And then the next day he will cut back and then well, from the cutback, he will layer and get everything looking great. So not only patients all over the world, but many dentists from the world are going, flying to him, staying for two days to have their makeover. But okay, if you haven’t seen his stuff, then maybe you cannot comment.

[Marco]
But this is the same that Marco, just because you are talking about this, Marco is doing the same, Marco is doing two things. He started doing what? Using Xgl to doing the injection to the final shape. So it was injected with DC after he was doing a cutback and he was layering 300. Now instead he is doing what he do two different indexes.

One for injecting the dentine and the al shell after he is doing alce mammals, all these kind of things, and that he has a second stent for injecting the enamel. So he has also the texture, the anatomy. 

[Jaz]
So you get the both benefits. You get the polychromatic result. with the method of injection molding. 

[Marco]
This will be the election of Mark Marconi. I show you a case. This is Ani, this is the case that he is doing and this is the result that is able to obtain. You see, you can get both things of the world. Of course you need more time. You need two indexes, two Exaclear standard one. There are more steps, but for people that wanna go in the direction, we will discuss also about this.

Of course the workshop with Marconi will be about the single xgl, the workshop, because it’s a beginner workshop, but during the lecture you will see Marco’s technique. You see the innovative customize, the ebr, the hind index and updated clinical procedure. So this will be the lecture from Marco. It will show about also this technique. So it will be the summit will see all, everything that it is around injection molding concept plus some modification about layering for people that it is into these kind of things. 

[Jaz]
And of course I know we talk about Injection Summit, but you know, you also do the Bioclear course in English and in Italian, so maybe I’ll put some links for that, for those who want to learn that. Definitely. Again, I wanna take a group of dentists back. The same group actually there, our WhatsApp group, we want to actually learn from you, so maybe one day we’ll arrange that as well. So I’ll put all the links. Marco, thanks so much for your time, for your passion, for your authenticity, for your philosophy, for your kindness. And fingers crossed we meet again in November and I can convince my wife. 

[Marco]
You know, the film in Padrino. The Godfather. 

[Jaz]
The Godfather film. Yes. 

[Marco]
I am sending a gift to your wife. She will not be able not to accept. 

[Jaz]
An offer she can’t refuse. Let’s see. 

Jaz’s Outro:
Well, there we have it guys. Pray for me for, I shall ask my wife today if she’ll let me go. And I mean that in a nice way, right? I mean, it’s one of those things, right? That marriage is a partnership. So it’s a joint decision. Whenever I go away or she goes away and it’s work related, it needs to have some sort of synergy. It needs to be planned. I’m gonna get a little bit philosophical here, right?

‘Cause you know, one of my highest values is family. And to give you some context, right? As a father, like you get woken up by your children early morning, 5:00 AM sometimes, or in the middle of the night. You’ve all heard me on the podcast talk about how my second born son in my firstborn, terrible sleepers, I’m up a lot at nighttime.

Either getting a milk feed or calming my children down. And it’s a common thing amongst us parents and those of us committed to a partner. We have to have that dialogue. We have to kind of get what we call level one permission. And so let me read out this quote to you. When nobody wakes you up in the morning and when nobody waits for you at night and when you can do whatever you want, what do you call it?

Freedom or loneliness? Right. So to be able to be in a position where I’m gonna be able to check, hey, can I go through this event or not, is what family is all about. So I’ll keep you posted if I will be going to Milan, but for those of you going super jealous, for those of you interested, again, I’ve put the link below, check it out.

It does sound brilliant. And hey, if due to family reasons or whatever, you can’t go. Don’t worry, there’ll be plenty of more opportunities always. But whenever you can, I’ve just learned that whenever you can go somewhere and feel energized by the people and that magic of in-person events is just, you can’t beat it, right?

It’s one of the times that, like me personally, when I go to like a music concert, I’m excited, but I’m actually so much more excited when I’m going to a conference. I feel energized. It is always a highlight for me. So for me, call it sad, call it geeky, whatever. I am far more energized when I’m going to a dental conference than I am for when I’m going to Wembley to see a singer I love.

So let’s keep the magic of in-person learning alive, my friends. Go and support these conferences that are out there and always keep learning. Thanks so much again for listening to the end. You can claim CE or CPD for this episode. You’ve just done all the hard work. You’ve listened, answer the questions, get 80% and Mari from Team Protrusive will send you your certificate.

You need to be on the app to be able to do it. You can make an account on www.protrusive.app and unlock 380 plus hours of CE or CPD. Don’t forget that you can download the premium notes for free. The new and improved the elevated premium notes for this episode by visiting protrusive.co.uk/im.

I’ll put that link in the show notes as well. I hope you absolutely love it. Please do comment if you did download it and what you thought about it, and of course, join us on the app. As always, thank you to all of team Protrusive, without whom this podcast would’ve died many years ago. But thanks to their support and your support Protruserati, we’re going from strength to strength.

We’re making learning fun. We’re making you fall in love in dentistry all over again. In fact, this reminds me of an email I literally just got yesterday. I won’t say his name ’cause I didn’t get his permission to read this out loud, but he’s a board certified prosthodontist. I won’t say from which country.

And we had a little email exchange about occlusion and stuff and he said, by the way, I love what you stand for. For a long time, I hated being a dentist. It caused me so much stress. This is a prosthodontist, by the way, guys. I recently found my passion for it. And your attitude and passion towards dentistry is what I am striving for. 

My friends, this is what it’s all about, right? There’s no point being in this stressful profession if you resent being in it. You need to change something to change your environment. You need to change who you hang out with, you change what you listen to. If you are not happy, something needs to change. 

This could be your practice. This could be your working hours, your working days, the techniques you’re using, the education you’re receiving. There’s so much to do and that’s why Protrusive is dedicated to your success. I’ll end with that, my friends. I’ll catch you same time, same place next week. Bye for now. Do not forget to hit the subscribe and the like button.