To Crown or Not to Crown: Exploring the Direct Composite Advantage

Most of the people that said they didn't want another crown were because they'd already had a crown and it didn't fit right. It didn't feel right. The gum didn't feel good. Or the crown had then needed a root canal and the root canal then needed to be redone. And then there was a fracture and you've gone down this tooth restorative death cycle and they were looking at an implant and they realized the crown was, in their mind, the first thing that kind of put that trajectory kind of in front of them. So mostly it was people that had had a poor experience with the crown. Welcome to the Phil Klein Dental Podcast. For years, when faced with a large cavity prep, our go-to solution has often been an indirect restoration, a crown or an onlay sent off to the lab or milled chairside. But what if we told you that in many cases that approach might be more aggressive than necessary? And on top of that, many of our patients are not particularly thrilled about getting their teeth prepped to accommodate an indirect restoration. With today's newer materials like highly filled nanocomposites and advanced adhesive systems, GPs have the capability to create strong, long-lasting, and minimally invasive restorations right in the operatory in a single visit. In this episode, we'll explore why direct composite procedures are quickly becoming a preferred alternative to traditional indirect restorations, and how you can use what we call the hybrid technique, like deep margin elevation, and model-based composite crowns to deliver exceptional results without prepping away valuable tooth structure or sending cases to the lab. Joining us are two experienced clinicians, Dr. Lauren Rainey and Dr. Mauricio Watanabe. They will share how the use of highly filled nanocomposite materials in their techniques are transforming the way they restore teeth and why patients are loving the results. So if you've ever wondered whether that crown prep was really necessary, Stay with us to find out. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Rainey, Dr. Watanabe, welcome to the show. Thank you for having us. And Dr. Watanabe, you're in Brazil now, correct? Yes, yes. In fact, I work in Brazil. I'm in a Brazilian dentist. And now I'm in my private practice. You're in private practice. How is the weather in Brazil right now? Where I live, it is very, very warm. Brazil is very large. And only in the south, we have winter like you have. Right. Okay. So you're in season with us. Yeah. Okay. What part of Brazil are you in? I live in the countryside of the state of São Paulo. But I live apart from the capital. 500 kilometers. But I have, I travel a lot. I have a course in Brasilia, at Brasilia, capital of Brazil. So it sounds beautiful when you say countryside. I'm sure it's a beautiful part of Brazil. Yeah, yes, I love it. Yeah, you're going to live a long time, Dr. Watanabe, enjoying the countryside. There is nothing wrong with that. And all of our very urban dentists are envious to think how it might be to practice in a countryside. All right, maybe not. but some of us okay let's begin talking about some dentistry here let's begin with Dr. Rainey with so many indirect materials that are available today and the advancements in our digital impression taking ie the intraoral scanner as well as the advancements of our dental laboratories why are you focusing on direct restorative composite for so much of your restorative work that's a great question it wasn't something that i ever really intended to do it was because patients were asking for something that was different um if i had a quarter maybe maybe we've talked about this before for every single time a patient said i really i don't want another crown is there like anything else you can do that i mean i could do laundry in college for many many years with all those quarters for patients asking me to do that and so that was kind of the premise for me learning more about what composite can do for us and what direct restoratives can do for us we don't always need to pivot toward a veneer or a lab fabricated restoration part of that is also that When I was an owner in my own private practice, there was a fee for a scanner and then additional fees for mill. And I wasn't in a position at that point in time to make like a mill kind of investment. So I was still relying very heavily on a laboratory to be able to help me provide those kind of. cases. And it really was just kind of an organic, okay, patients are asking, let's figure out how to do it. Yeah. So let me hit on that point about patients asking. So it sounds like to me, your patients have a high dental IQ where they're aware of the, I mean, I don't know many patients that my friends who are dentists that are treating are really focused in and dialed in on materials. Now, were they concerned more with the fact that more tooth structure had to be removed in order to accommodate indirect? Or were they just more enamored by the idea they can get this stuff just laid on the tooth with some bonding, put this stuff on, cure it, and we're good to go? What was the enticement that lured the patients into your composite restorative world? It was a combination of both of those things. I had a number of patients who'd had crowns done, especially on anterior teeth, and they get up to go to the bathroom while before they were going to have their impression taken, they look in the mirror and saw what a crown prep looked like. One patient in particular who was just, she said she was horrified as to how much tooth structure was missing. We all know what an anterior crown prep looks like. It can be a little bit disarming if you're not really sure what you're looking at. Others, most of the people that... said they didn't want another crown were because they'd already had a crown and it didn't fit right. It didn't feel right. The gum didn't feel good or the crown had then needed a root canal and the root canal then needed to be redone. And then there was a fracture and you've gone down this tooth restorative death cycle and they were looking at an implant and they realized the crown was in their mind, the first thing that kind of put that trajectory kind of in front of them. So mostly it was people that had had a poor experience with a crown one way or another. so that they knew that we could do something with composite they were like less excited by the overlaying of material uh definitely i've treated a lot of engineers and so as soon as you get into the engineering of an overlay everyone is on board uh but we didn't always get to that point initially it was because they were asking questions like Is there something else? Also, the cost of a crowd in the United States is significantly higher than an out-of-pocket cost for a direct restoration most of the time. And so I think it was a combination of those things that kind of led toward them asking those questions and then me being a good listener and listening to see, okay, well, is there a way that we can change this trajectory for you? And Dr. Watanabe, you're very much into direct restorative materials. using them rather than indirect techniques for a lot of your cases that maybe in the past you were using ceramics indirect. In fact, I prefer to use composite because it's much easier for us to make something more conservative. Perhaps that we need to do to use ceramics. It's much more specific. You need some... a specific thickness we need some situations that we need to remove tooth that already has some big cavity so when using composite even if you use it directly or indirectly, we can make it more conservative. Your main concern is conservative dentistry, minimally invasive procedures. Are you pushing the envelope, as they say, where you think that the tooth could be more at risk of a fracture down the road without having full coverage? In fact, when we use composite resin because of the bonding, because of the new materials that we have nowadays, We can restore big coverage even without covering a cusp. We can make it more resistant. The important thing is the longevity of the tooth. And so we need to be more conservative in everything we do in dentistry. So what are you looking for, Dr. Watanabe, on the materials themselves? What helps you make a decision on what to use? And then I'll follow up with you. Dr. Rainey, on that same question. Especially when we are talking about the restoration of posterior teeth, we need to be concerned about the resistance. So the mechanical properties are the main traits that we need to be concerned about the composite. Generally, when we have a higher filler content in a composite resin, we have a higher wire resistance and flexor resistance. And so generally we use a composite resin specifically for the posterior teeth. When we are restoring anterior teeth, I would prefer something that is optically more appropriate to layer. and use different colors and shades to obtain aesthetic restoration. But in the posterior area, I think the mechanical property is more important. So let me ask Dr. Rainey this question. So as we all know, As dentists, in large part, our chair time is the most valuable thing we offer our patients. I mean, that's what we're selling. We're selling our expertise on our chair time. So being efficient with time and resources by doing these larger composite restorations. you know, manually chair side, as opposed to a full coverage lab or a milled restoration where our hands aren't in it as much. You could see from the point of view of some dentists by saying, I don't have time to sit there and build these restorations artistically. It's very technique sensitive. I've got to make sure the teeth are very dry. especially when it comes to composites, because I don't have the moisture tolerance that I would perhaps with a glass ionomer. What do you say to that when they say, you know, that's just a lot of chair time, it's not an efficient use of my time to do these larger restorations with direct composite procedures? There are ways to make it sustainable in a private practice environment, for sure. I think it just depends, again, on what the patient is. looking for and what you as a provider like feel as your practice philosophy i think i once want to echo you know what Dr. Watanabe was saying We are concerned about the longevity of the tooth. And if you kind of keep that at the forefront of the conversation, that will help sort of dictate what you do. But I hear what you're saying. I hear what you're saying. You don't always have, you know, two hours to kind of dither around and do shades and colors and this, that, and the other. But I can do these in one visit as opposed to having them come back, you know, creating a temporary and having them come back. So there's chair time and efficiency in that regard. You know, a lot of these mills are. very fast and you can mill some of these composite restorations, you know, in what, eight to 10 minutes. So that can also be very efficient, but it just kind of depends on practice philosophy and kind of where your skillset is and where your skillset lies. And again, what your patients are looking for. So there are ways to do it both, both ways. So I would say you just need to look carefully at figuring out what your strengths are and what your skills are and what your patient demographic is looking for and kind of create that practice. to balance those things. But I think what you're both saying is that the advancements in the direct restorative field of composites have gone to a level. They're so advanced and they're so strong right now. And you combine that with good technique, good isolation. Then there's an argument to be made for saving tooth structure in lieu of cutting these teeth down. And sometimes you could do a conservative prep, but you still have to take. away, you know, enough tooth structure for this to work when you're going indirect. Either one of you can jump in on this. When do you draw the line? When do you say this tooth cannot be restored confidently with direct and we have to go indirect? I would prefer indirect restoration when we have a large cavity that we have some difficulties to sculpt. Indirect, we can do with composite and ceramic but nowadays i i use much more composite indirect composite restorations than ceramic indirect restorations because we can join the the conservative press because when we are prepping a large cavity we have a lot of sites that we have retention and we can just film with composite instead of removing with the burr so that's why i think that in this case where we have a large restoration and we also need to remember that when we are restoring directly with composite we have the shrinkage of composite during the polymerization and this will generate stress that can cause some problems after the polymerization. So I would prefer for larger restoration, an indirect approach, even using composite or ceramic. But nowadays I would prefer composite resin. As an indirect, you're saying? Yes. Okay. Explain to me how that's done today, using composite as an indirect. we can use the the same composite that you use for direct technique but we just prep and this prep is just make the cavity like an explosive cavity to allow us to set the restoration to make it we fill the gaps we fill the irregularities we can use the deep margin elevation and after that we take an impression and obtain a model where we can fabricate our restoration and this restoration using a composite a regular composite that we already used for the direct technique we just sculpt it and we have an excellent access from all the signs that we can use our instruments And after that, we remove it from the model. And after that, just making the cementation. So I think that is similar to the technique that we already do with ceramics. But we can do it fast because we don't depend on an external laboratory to make it with an excellent quality. So just to recap what you just said. said, Dr. Watanabe, we did have a couple of spots where the audio was difficult to understand. So you use direct composite. We're talking about a large restoration. You're using a direct composite to fill in some defects in the tooth and also do a deep margin elevation, which means you're raising the restorative margin above the gum line where you have easy access. And then you want to conservatively prep the tooth to accept the crown. And then you're taking an impression. And then I think you're going to pour it up with a silicone model. I don't know if you mentioned that. And that will allow it to set the model very quickly. And then you go ahead and use the same composite that you did for the deep margin elevation and the direct composite work that you did on the tooth that was remaining. You use that and sculpt it up into a restoration. And when that sets up, when you light cure that, take that off, try it in the mouth, and then cement it in. And you have margins that are easily visible because you've raised them up. And so you've kind of got a direct technique mixed with an indirect technique, but you're using the same material, which is composite, which are compatible with each other. So I think that's what you were explaining. Yes. So Dr. Rainey, let me ask you this question. As far as doing direct composites on fairly large restorations, The case did not pass that red line where you know you have to use full coverage and you want to go direct. What is your track record been with those cases? How successful have you been? How long you've been doing it that way where you're pushing the envelope on direct composites? So I started doing some of these. sort of larger restorations in about 2018, 2019. But as we've talked previously, I sold that practice in 2022. So I had good track record from 2019 to 2022, but that means I'm still doing them. I just am not seeing the same ones from there. However, I am still in contact with some of those patients that I've treated and those ones from the patients that I'm still in contact with seem to be holding up just fine. And what's surprising to me, Dr. Rainey, is that back in the day, I assume it's still the case, crowns were expected to last five years. And you could do better with direct composites in many cases. Is that still the expected longevity of a crown, five years? I would expect crowns to last longer than that. But a lot of the insurance companies here in the United States would say that you can have a new crown after three to five years, depending on the carrier. I think on composites, they'll say that you can have the insurance companies will dictate that you can do another restoration on the tooth in the same location every two to four years, depending again. on the carrier and the coverage that the patient has. Now, I hesitate to let an insurance contract dictate when a patient can or cannot have the restoration that will give that tooth longevity and will give them the function that they need. But I think that is where those numbers tend to come from. I would say most of our dental restoratives will last a very long time. if you leave them on the countertop but some of our patients leave the practice and go and chew on a rock or fall down or you know stuff happens so it's not we're not working in a vacuum and i think probably Dr. Watanabe would agree right some of these restorations can last you know 10 15 years if they are done appropriately following the materials recommendations. And if you're using, I mean, he brought up, you know, anterior composites that he uses are different than the posterior composites. Their material science can be different. And so if you're following what these materials are made for, and whether that's zirconia or that's gold or that's composite resin, you know, nano hybrid, you have to respect the material that you're working with. What kind of materials are we talking about where you could do really large? uh heroic direct restorative dr raney what are you using in your office give us some examples of some kind of materials so for these particular restorations i'm using a lot of like the nano hybrid composites and many of them come in a bulk fill capacity. So you can get four to five millimeters depth of cure with most of those. So if you're concerned about access, sort of visibility, those can be really great in those situations. And there's a number of those on the market and a number of those I use in clinical practice, depending on the situation. But those are the most of the ones I use in the posterior. Do you have a particular favorite go-to composite restorative? Well, I tend to like the Admira Fusion Extra that's made by Voco. And that is special because it is a non-resin-based composite. It's based with like a silicon oxide in it. So it's more like glass, kind of like Emacs in a carpule that you can squeeze into the tooth. And again, that was all due to patients asking for things that were non-traditional composites, non-BPA and that kind of. That material just kind of like, I stumbled across it looking for an answer for a patient. So do you think these patients are doing some research on the internet looking for materials that aren't harmful to their health? They're reading about possibly toxic ingredients in dental restorative materials. And do they approach you in that viewpoint? I want to be careful about how we answer that because I don't think a lot of dental materials that we're using are in fact toxic. But yes, patients are going on the internet. They are going online and they are finding answers to questions that they have outside of the dental practice. And that's through social media or literature reviews that the patients are armed with. information and information can be helpful and it can also be really challenging. We're in a time right now in the United States where there are going to be some big questions about, you know, fluoride and water, and that's going to just raise a whole other can of worms in dental practices as to like which materials have fluoride in them or which of them don't. But yes, I think it's great when patients are interested, but sometimes that can inhibit our ability to put that in the bigger scheme of the science that we've been trained on and learned on. And again, for all the dental manufacturers out there, they spend so much time and energy and money on, on research to make these kinds of materials that both Dr. Wasimov and I use in clinical practice regularly. They make them incredible. There's so much science packed into those tiny little car fuels. It behooves us to pay attention to what's in there and to, again, kind of respect the material properties in there as well. And I certainly want to ask you, Dr. Watanabe, what your favorites are, because you're a real user of direct composites, both for direct procedures, as you described, and also indirect, or that combination of direct and indirect, where you do the deep margin elevation, and then you go ahead with the silicone. model where you sculpt out that composite right on the model and then put it cement it back into the into the mouth and you're using um obviously a highly filled composite any favorites in that area yes i i like to use grandioso for the posterior area and i i can also use like a supreme ultra the reason why i'm asking um and i'm talking to our listeners is that Many times we get, in a week, we'll get emails and say, you know, it was a great podcast, but I didn't, what good is it if I didn't get some recommendation from the key opinion leader? So from the practical standpoint, we like to ask some of the speakers what they use so that our listeners can make their choice. It's of course up to them to make their choice, but it's nice to know the name of the product goes with the discussion. Certainly makes sense. Is there anything either one of you would like to add before we wrap up this episode? uh please do about the the products or the deep margin elevation i like to use rambioso heavy flow that is a flowable material but with a higher filler content and when i use this composite I prefer to use Grandioso as the material to fabricate the restoration so what you're saying is Dr. Watanabe you want to stay with the same brand in this case the exact same product within the same brand which is the grandioso heavy flow both for the deep margin elevation and the indirect fabrication of the composite crown on that silicone model that you later cement in because that interface will be compatible. The same system because we have an interface with the two materials. And when we use a different material from different brands, we have a difference in the polishing. So that's why I would prefer to use both of the same brands. Thank you very much, Dr. Watanabe. Really appreciate it. Thank you, Dr. Rainey. And we'll be seeing you on a future podcast because we have other stuff to discuss. Have a great evening. Thank you. Thank you. Thank you.