Anterior Direct Composite Restorations - The Ultimate Additive Solution

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. If you're a dentist who is artistic and enjoy creating beautiful anterior restorations, and at the same time, truly care about conserving tooth structure, then you probably would love to hear more about the ultimate additive solution. And that's the topic of our discussion in this episode. It's also covered in Dr. Mehrdad Razaghi's webinar. titled Anterior Direct Composite Restorations, The Ultimate Additive Solution. His webinar was so intriguing that I asked him to join us on today's show. You can watch his webinar on VivaLearning.com. Just type in his last name, Razaghy, R-A-Z-A-G-H-Y, in the search field, and his webinar will come up. It's really something to watch. Dr. Razaghi is not only a phenomenally talented chairside dentist, but also a full-fledged researcher joining Dr. Pascal Magnier's research lab at Herman Ostro School of Dentistry of USC. Dr. Razaghy has contributed to various books, journals, and publications in the world of restorative and biomimetic dentistry. His expertise is in dental photography, biomimetics, and minimally invasive and additive dentistry. Dr. Razaghy, it's a pleasure to have you on the show. Thank you, Phil. It's a pleasure to be here. So the webinar that you did, which is getting great reviews, by the way, great feedback from our audience, the title of it includes the term, The Ultimate Additive Solution. So I just wanted you to comment on what you mean by additive in the front end of this podcast, and then we'll get into more details. Absolutely. This really goes back to my passion for what we call biomimetic dentistry. Everything that we do in dentistry, what could it be and how could it happen so that if you're replacing tooth structure, we can be as close as possible to the biology, to the nature of the tooth itself. And as someone who was always motivated by that, that took me back to... What can we do to not remove in the first place? Because nothing can replace nature like itself. And that's where my passion for preventative and additive dentistry began. And really in this lecture, my goal was to show the audience that if we develop the skills with layering composite and using the composite in a way to create really nice aesthetic results in the anterior region, then we can just offer more additive solutions to our patients who are not happy with their smiles, especially their anterior, and they're seeking to go through smile makeovers, and usually the treatment ends with it. veneer preparations, crown preparations, and more aggressive dentistry. And most of these cases, especially if you are concentrated in younger patient population, could have been just additive. And that really was the core of our lecture. With additive composite, we can make a big difference for these patients. And if we can avoid removal of teeth, even buying them 10, 15 years before they go to. veneer restoration it's a big win for the dentist and the patient yeah there's no question about it the conservation of tooth structure is a philosophy that is so important I think it's becoming more accepted and more practiced throughout the profession of dentistry Versus in the old days when, you know, we would see these magazines on the front cover of the magazines, we'd see these veneer preps where these teeth would just be brutalized with depth cuts, you know, straight across these massive depth cuts with these diamond burrs. It was horrific to me as in practicing endodontist at that time. I looked at that as like horrible, uh, blasphemy. Yeah. It was just, so what you're doing, what you're doing is fantastic. Now I assume that the success of what you're doing, not only. is related to your skill set, which I want to ask you about what skill set is necessary for a dentist to pull this off in a very aesthetic way, but also the advancements of materials, right? Because when you're using direct restorative materials that are at the level they are today, you can really do some magic with it. Absolutely. So if you can comment on the quality of the materials that are out there that's giving you the confidence, the underlying adhesive capabilities of the layers beneath. those additive layers? And also, what's the skill set that is really required by the GP who wants to do the kind of things that you're showing? Absolutely. And really, that is the most important part because to be able to do these additive anterior composites you need to have a very profound knowledge of morphology and with this huge wave in dentistry of everything going digital we are starting to lose that interest for tooth morphology and sitting down and doing a wax up and carving the wax yourself with your hands. And that is really the heart of the skill set that practitioners need to do these anterior composites. Because if you think about it, when you're doing anterior composites, you're hand sculpting everything, every single layer yourself on the patient's mouth with the rubber dam on. So you need to have a very good understanding of shape, color, and morphology. And the best way to gain that is to start doing these diagnostic wax ups. When I'm doing any anterior case, I almost do the wax up myself because really that is your first trial to understand, first of all, how much material you're adding to this patient's anterior teeth to give them what they want. And it's your first practice of... carving the design that you have in mind. So when you're doing the composite, it's not your first time doing this. Of course, these wax-ups can be done digitally, but I feel a big gap between a digital design and then trying to do that with your hands. Other than that, really it comes down to having a very nice, deep understanding of color. And today with the composite systems that are out there, it's fairly easy to say that you can... create restorations that are extremely natural and have all the effects you would want to see from a natural tooth structure. Most of the composites that I showed during this specific lecture was from this really nice composite system by GC called Accord. And this has been really the core of most of my anterior restorations. And the reason why I'm drawn to this system is that We have finally found a system that's not only simple as far as color distribution, but also has enough fillers so these anterior composites can last and be functional. For the longest time, all dentists that were interested in this kind of additive dentistry were... two worlds of using micro-hybrid composite, which has amazing translucency and polishability, but that comes at a cost, and that was the lack of filler components in these composites, so that they would chip and break. Now, the nano-hybrid composites, of course, are much better as far as strength and functionality. And finally, I think we are getting to a time where we have systems like Accord. that has found just the perfect combination between the two. To be filled and strong enough so that it can function for someone to have anterior guidance, canine guidance, and not break, but still have those optical and aesthetic properties to allow the dentist to layer and produce something that's acceptable. So when you teach, you probably get the question about single-shade systems. Yeah. And this is something that's been marketed by manufacturers, and some dentists are having great success with it, in their opinion. That's something you probably look down on a little bit and frown upon for a number of reasons. So if you could just address that single-shade concept, where a dentist really has simplified his life using that, the time it takes for you to do it your way. I'm sure you get incredible aesthetic clinical results using, for instance, GC Accord and other products that you like. But the chair time has something to do with it, right? I mean, it takes a lot longer. So then you have to worry about the fees, which we'll get into later. So if you could start with the single shade concept, knock that off quick. You don't have to spend a lot of time on that. And then let's go into how long we're talking about for some of these procedures chair side. Absolutely. I would say this single-shade system was really a great product that came into the market from many different manufacturers. And really, it's simple. Everything is in spherical, round shapes as far as the particles. are used to make these composites. So it has the ability of mirroring everything that's around it. And I'm not really against using these composites in the posterior region. Time is an issue and dentists want to just find an easier way to create restorations that more or less match the color. However, this in the anterior region, if you really want to create something that you would call excellent and ideal as far as aesthetics and optical properties, is not my go-to at this moment. I've seen that there's dentists that can create really nice results with one shade. And it really comes down to the environment and the teeth around of where they're doing the restorations. But there is optical properties that... really do not apply here if you're limiting ourselves with the one-shade system. And we're talking about concepts like fluorescence, opalescence, and translucency. These are things that you cannot really achieve by this one-shade system. And if you're... just trying to do an additive single central on a patient that has beautiful natural teeth with translucencies. You have to have these concepts on mind and you need to layer in a way that in different lights when this patient speaks and gets photographed or filmed or just has conversations and no one can practically look. at that tooth and realize that this patient has a direct composite there. Otherwise, we had failed the patient. How do you define the fee for these additive full coverage composites? Or maybe they're not full coverage, but they're additive and they take the time, the layers. How do you work the fee for that so that it's commensurate for the amount of work and skill that you're putting into it? Correct. And really this, before I define the fees in any practice, this starts with patient education. The first and most important step is educating our patients and helping them realize that to be able to be additive. yet create something that is flawless and aesthetically pleasing, it takes time. It's not just an alternative. It's basically a process for us to be able to create that. Then in the light of educating them, you explain why we use rubber dam restorations, why we would use a wet mock-up to really pick the best shades that match the patient's teeth. And, you know, this is time-consuming, not just because of the rubber dam and layering them and doing the wax up. I've had cases where... just spent 20 minutes picking the shades that I need to use. Because sometimes you're dealing with really complex shapes and characterizations and shades, and especially if you're doing single tooth additive, single restoration composites, it becomes fairly challenging. But as long as the patient understands that the value... gain by being additive and not just prepping for veneers and crowns then they are okay with realizing oh okay I understand this is going to take an hour and a half to two hours for one tooth and I will probably have to pay close to price of a veneer even though this is a composite But I am practically saving myself of getting six veneers because that's what I hear most of the time, the alternative. It's a single tooth. Even if you do a veneer, the laboratory is not going to be able to match it. We better do two, four, or six veneers to just give the patient a good smile. And that all started with a single fractured tooth. Yeah, that's an amazing service to your patients. That's an absolutely amazing service. And the conservation of tooth structure. and the whole aspect of doing minimally invasive dentistry. How does the biomimetics play into this? Because I know you're big into biomimetics. It is. It really is all about tooth conservation. And if someone understands the biomimetic dentistry deeply, with that comes a very... deep knowledge in how to bond to tooth structure, how to gain a strong bot to dentin and enamel, so that when you function on this tooth, it can function like a natural tooth. So biomimetic dentistry is a huge topic. I mean, you've just seen amazing individuals like my mentor, Dr. Pascal Marnier, has now two... big series of books on just the concept of biomimetic dentistry. And it's not just about aesthetics. It's about biology. It's about understanding function, physics, and really the aesthetics as he puts it is the cherry on the top. When someone has a collective information on understanding the morphology and the biology and what it takes to bond to this tooth so that it can function like the rest of the teeth, then that's when if you add aesthetic knowledge on top of that, you can create a composite restoration that can last for a very long time. Yeah, and I was going to ask you that. Some of the dentists that I talked to on our podcast program, They're just really changed their whole confidence level about what they could do with composites. Some of the key opinion leaders I talk to say, hey, I could have the tooth literally broken down flush at the gum line. I don't care. I'm going to be able to use adhesive dentistry and I'll put a whole tooth on top of that without a post. Are we seeing that across the board with some of the... types of dentists like yourself, Dr. Oz, that are leading the way in research and pushing the envelope with composites. Absolutely. And there is a big wave of dentists understanding that bonding and the ability of bonding to a basically soft and non-retentive surface works. Technology actually has been there for a very long time. Believe it or not, that's how airplanes are made. This is bonded pieces of composite together. And now that technology has been here, that knowledge has been in dentistry for a very long time, it is very difficult for many dentists to move from that. retentive-based restoration and dentistry, which means crowns and anything that we do that causes retention to fully trusting and doing bonding, non-retentive dentistry per se. And the reason why this switch is difficult is because it is fairly technique sensitive. For you to be able to bond a flat piece of ceramic on a flat tooth that is completely non-retentive, you need to have perfect isolation. You need to understand how to condition the tooth structure, which if you want to do it ideally is more than four steps. And you need to understand deeply how to condition the surface of the ceramic. That is extremely time-consuming and technique-sensitive. This switch is not something that a dentist that is used to retentive dentistry can jump to overnight. It comes with practice, knowledge, and a slow switch to really trusting that additive dentistry works. So to wrap up this podcast, and it's been very enlightening, Dr. Roz, really appreciate it. How do you educate your patients on additive, restorative, composite dentistry versus... veneers ceramic veneers you know there this woman comes in her neighbor had six veneers she's been bragging about how beautiful her teeth look and she's she wants to come and have veneers and you take a look and you realize you could do some really fantastic minimally invasive additive dentistry having that in your mind saying this is the way i want to go with this patient after she's just seen her neighbor with six veneers that look like perfect teeth, you know, they're straight out of the laboratory. How do you educate this person and how do you proceed with your treatment plan? So basically, we spend a lot of time, if we think that the patient is a good candidate for additive dentistry, educating them what it is and what they gain by not having the teeth shaved down. And in some cases, really, the veneers... are the way to go it really depends on the case but many cases you can at least start by additive composites so the education begins with them understanding the value of being additive and a big part of this really goes back to your last question which is extremely important because your fee structure as a dentist needs to reflect that. It is impossible for you to be an office that's completely in network with all insurances and have that population of patients and do this kind of dentistry. The dentist needs to have raised fees reflecting their overhead and the time that they need to spend on these additive composites. The patient needs to understand that. And sometimes for more complex cases, you need to... an hourly fee on top of what you're charging with these composites so that it makes sense. At the end of the day, the practice needs to survive and the dentist needs to be happy. I mean, this is not museum dentistry where we just sit down and do one fantastic case a month and we just publish that and then the dentist look at it and they say, there's no way I can afford to do that. I have staff, I have overhead. Once the patient understands the value of this type of dentistry, and then with that, they understand, okay, this is the reason why I'm paying almost the cost of a veneer for a single tooth additive dentistry because I am potentially removing the... cost of six veneers once that clicks in their heads and once they understand what we're trying to do and what it takes to do that flawlessly meaning rubber dam wet mock-ups and everything we talked about in the lecture then it becomes extremely easy they accept the cost they accept your time and if you start doing that as a practitioner you see this pool of patients that just come your way and it becomes your niche and that really is how it started for me I did a few cases a month now they go around all these patients and anyone that has a little defect and is thinking about getting veneers They direct them to you because they know you do this kind of dentistry and slowly your patient population changes. And that's one of the best things that has happened to my practice. Yeah, that's a very exciting thought to do what you love, follow your passion, and then the patients just keep knocking on the door. It's like there's nothing that could be more fulfilling than that. And do not be afraid to charge for it. Because you need to explain to your patients what you're giving them. You need to explain to them how much trouble you're saving them by doing this with additive dentistry versus doing veneers. And they will 100% appreciate all your efforts if you educate them correctly. Yeah, and I also want to commend you on your photography in your webinar. You know, I've been around. uh, online education for 30 years. I started this company a long time before anybody knew what online learning was. And yeah, photography is super important in presentations and your stuff is just outstanding. It's just a beautiful presentation. And I did in my introduction, talk about the webinar, but again, I'm emphasizing to the audience to check out this webinar. Just go to VivaLearning.com and type in, uh, Razagi, R-A-Z. A-G-H-Y in the search field. And you'll see the webinar, The Ultimate Additive Solution. It's actually called Anterior Direct Composite Restorations, The Ultimate Additive Solution. And it's fantastic. So you guys, whoever's out there, we'll check that out. Thank you, Phil. Thank you so much for this time and all your kind words. And this really is not magic. It's a type of dentistry that anyone can learn. It all starts with understanding the philosophy and starting it slow and practicing, practicing, practicing. And you start doing wax ups that this is really. You know, the true love for dentistry, the reason why we all love dentistry is the artistry in it. My message to everyone, especially in my generation of dentists, is that, yes, digital dentistry is good, but it's only a tool. Don't let that distract your love for the artistry of dentistry. And that's why to this date, I... every single case of additive composites that I do for my patients. Dr. Razaghy , thanks so much for your podcast time and have a great evening. We hope to have you on another show soon. Thank you, Phil. Nothing but a pleasure for me. I appreciate your time as well. If you've been enjoying our podcast, we'd love to hear your thoughts and feedback by leaving a review on your favorite podcast platform. whether it's Spotify, Apple, Google, or any other platform you listen on. Leaving a review is a fantastic way to support us and help others discover our show. Thanks for listening. See you next time. you