Achieving Indirect Restorative Excellence: A Discussion with Dr. Matt Nejad

You're listening to the Phil Klein Dental Podcast. So things are certainly moving fast in the area of digital dentistry. And as dental clinicians, it's incumbent upon us to be knowledgeable on what is out there that can make a difference in helping us deliver better dental care to our patients. Today we'll be talking to Dr. Matt Nejad about a variety of things, all relating to utilizing digital dentistry to restore the tooth in the most conservative and biomimetic way, and at the same time making the restorative process enjoyable for the dentist and efficient and profitable for the practice. Dr. Nejad discovered a lot of efficiencies with digital workflow, but what was most surprising to him was how he could mill restorations that were extraordinarily precise in their fit. In this episode, he talks about a myriad of nuances related to his indirect restorative processes, including the benefits of a fully crystallized CAD-CAM block, whether to fabricate and deliver a CAD-CAM restoration in a single day or make it a two-day procedure. He talks about 3D printing. now and in the future, and he tells us what makes him decide to do either a direct or indirect restoration. Dr. Matt Nejad is an expert biomimetic and aesthetic dentist practicing in Beverly Hills, California. He is a fellow of the Academy of Biomimetic Dentistry, the highest level of accreditation possible, and serves as a scientific advisor to mentor and train dentists. He provides education and training through the Najad Institute for Biomimetic Dentistry. Dr. Nejad, welcome to the show. My pleasure. Thanks for having me. So many of us dentists who are considered late adopters have been in somewhat of a holding pattern. And what I mean by that, Dr. Nejad, is that they're going on with their traditional methods of restorative dentistry using techniques they've employed for years and years. Many of them use the same techniques that they learn in dental school, which is understandable to some extent. But fairly recently, we're seeing the trend shift a bit. And many of those same dentists are now beginning to add digital tools into their practice. Typically, one of the first things dentists add is to their workflow is an intraoral scanner. Then they may pick up a 3D printer because they can't wait to get rid of the alginate and the porting of models with stone because that's a great solution for that, at least to get started. What are you seeing in this trend? Are you seeing the same thing among your peers that transition out of traditional analog dentistry into digital? And what do you see in the next year or so? Yeah, absolutely. I mean, you nailed it right there. resistant or reluctant to change and that's easy to understand but you know uh with social media and how information gets out there you see these advantages or the benefits they can bring to your practice and yeah i'm definitely seeing more people implement these type of technologies. I teach courses and people are always asking about like integrating intraoral scanner and CAD CAM, even though that's not the focus of my education on biomimetic dentistry, it goes hand in hand with it. So I've seen, just like you mentioned, more people getting into intraoral scanning, but you quickly realize if all you're doing is intraoral scanning and sending out to lab, I would. I would argue it's not really saving you too much time and giving you too much benefit because you can take a PVS impression, walk away, come back a few minutes later and be ready to go. It takes probably even more training for staff to pack up the lab cases or to use the ways that you transmit that to labs. So you quickly start to get into or get interested in 3D printing and CAD CAM and all these other supplemental digital. technology, but it's the digital era of dentistry. And there's so many benefits that come from incorporating these things. You just have to get over that basically burden or over that hesitation to, you know, jump in. Yeah. And I'm hearing that from other top clinicians that speak on our program, that lecture, they say the same thing. It's that hurdle. Once you, and that's with anything in life, right? Whenever you start something totally new, it's a change in behavior and you're used to something, your staff is used to something. But, you know, digital radiography, we kind of went through the same thing. People were taking films. When I was an endodontist, we had a dark room. And, you know, we'd go in there and dip it. My wife was my assistant. And, you know, she'd come out with fixer all over her scrubs. And that's the way it was. The end of my career did catch the beginning of the digital radiography revolution. So that was really a lot of fun for me. How significant has digital dentistry been for your practice? Let's talk about what you're doing because you did a tremendous webinar on Viva Learning on biomimetic dentistry using indirect restorative techniques using digital tools such as CAD CAM Chairside. And it was a really phenomenal presentation. I got to tell you, I really enjoyed it. And I recommend that to all of our listeners. Just look up Najad, N-E-J-A-D on VivaLearning.com and you'll see it. So specifically to your practice. What has CAD CAM chairside milling done for you in all aspects? Efficiency, prognosis as far as the success of your cases, everything. I'm glad you enjoyed the webinar and thank you. It's made a huge impact. I too was reluctant to get into these things. But, you know, once you have the internal scanner, you jump in. And I saw that I didn't have much utility if I didn't go further with it. I had some limited uses and I found myself not wanting to, you know, commit to restorative with internal scanners. And I've had a few generations and different brands of scanners over the years. But basically, my reluctance was related to thinking maybe it's faster or it's cheaper, but it's not better. But as the technology continued to... I started to see that you can, you know, use CAD CAM to get a really nice detailed anatomy. And I have my own lab in-house and we, you know, pride in doing the best work and trying to constantly innovate and get better and better. But when we saw the anatomy this could do and how it could fit into our workflow and free up my technician's time to do more, put more energy into anterior restorations, we decided to go with a CAD CAM milling machine. And we've been very pleased. is amazing. Our fit is fantastic. It does streamline our production. We can do stuff in same day or sometimes not. Now we can talk about that too, but I don't always do same day for these things. But I would say in total, it's made my workflow smoother, less occlusal adjustment, just so many benefits. And I'm not sacrificing the thing that I was worried about, which was having very basic looking restorations that don't give me that pride and satisfaction. that i like i like producing stuff that i look at and you know that challenges me to improve all the time now do you do your own design in the software for these cases yes i do um that started with doing smile designs myself i found it important to you know no case know the case as well also i'm a big believer in you have to be the master of your technology you're going to train staff you want to delegate things but when staff comes and goes or if they tell you something's not possible i've just never found the um i've never found it found it to be true that like i can rely on someone else to really maximize the capabilities i have that personality type that always wants to you know push further and see what the software or the machine or the technology can do. So yeah, I learn it and my goal is to train it, you know, but I have to be the master of it. So I do my own designs right at this moment. Even my technician can do the designs. He's excellent at doing our restorations, wax ups, everything. So it was natural for him to, you know, make the jump to digital. It only took him like, you know, a day of practice to jump in. And it's, you know, the same skills that you have from analog translate to. you know doing the anatomy it's very intuitive it's not it's not hard if you know your anatomy if you don't know your anatomy you want to spend the time to learn that. And I think that's an important skill to have. You're finding that you're getting better anatomy by doing CAD CAM chair side. Is that because you're doing the design work? Because if you send out your scan, your intraoral scan as a file to a laboratory, why can't they also create really super good anatomy if you're using the right lab and you have a good relationship with the lab technician? Oh, don't get me wrong. You can. I mean, with top level lab work, you can always get. equal or better anatomy it's just i always think milling was always you know second class in terms of anatomy detail limitations of burr size and everything like that so i guess i should say i'm able to get the quality of lab work that i expect from top level labs and in the case of my office at that particular time i had a technician whose skill set was mainly anterior his posterior anatomy was admittedly not his strength so we were able to elevate just because of his knowledge there you know so we can start with a library to do a little bit of customization and oftentimes be having more natural looking anatomy because you're starting with that natural starting point of the library tooth. But I think if you're comparing to top level labs, yeah, of course it's possible. It's more impressive that now milling can actually recreate some of that finer detail, that secondary and tertiary anatomy. And, you know, some people don't care about that. I totally understand. But, you know, the fact that we can do it and it can give us that additional ability opens it up to a lot of practitioners like myself who are interested in that type of stuff. You know, you can do whatever anatomy you want. You can do basic all the way up to advanced. So you have a whole full CAD CAM chairside milling. set up in your practice, but you mentioned in your webinar that you don't always do same-day dentistry all the time. Explain to us why you don't and what are the indications for not doing same-day dentistry. Yes, I think same day dentistry has a lot of benefits, but depends on your practice setup. So I've looked at it closely. So for my situation, it makes sense to do same day in situations where patients traveling from out of state or out of country or extremely busy. But other than that. I find that I can have more productivity in a day by doing a two-visit approach because I don't have multiple chairs. That's not a very common situation, but I work out of one room four days a week. On the fifth day, I do my exams and consults and all that stuff using the whole office. the patient would either have to leave and I would have to be trying to squeeze a short procedure in, in between, which is pretty uncommon for me to do. Or I would have to basically book up a whole day. And instead of having either my staff or technicians, now that I've been training to do the anatomy, I would probably be kind of locking up my time. If I had multiple rooms, it'd be a different scenario, of course. But the fact that I don't makes it overall more productive for me to do a two-visit approach. Plus sometimes... find that it's enough for the patient, depending on how long you take to do the level of quality you're shooting for. Sometimes I think they actually prefer to have a couple visits, but there is no one size fits all. We offer that. And when we do offer it, oftentimes because I do find that it affects my productivity, I charge a additional same day fee. And sometimes that's well received. And I shouldn't say well received. Sometimes that's perfectly fine and it makes sense for the patient. And other times. they, you know, opt to do a regular turnaround time and that works good for me too. It used to also be because I would take too long in the process from going from scan to, you know, ready to deliver. But we have definitely tightened that up, especially being able to use like pre-crystallized blocks and things that will save significant time for us. You mentioned in your webinar that you're seeing the adaptation of your margins at levels you've never seen before. What do you attribute that to? Because there's so many different factors that affect the final result of an indirect restoration. Yes. Okay. So first, it was a pleasant surprise to find that benefit. I did not get into CAD CAM thinking that I was going to improve my precision of fit or margins or anything. I practice biomimetic dentistry. I cement my restorations with heated composite. I've always done that since dental school. I learned this in dental school, and I've been doing it faithfully ever since. I see tons of advantages for that. We can spend forever talking about that. What happened was when I got this milling machine and I already had been scanning at the time, I started to notice and... started to notice a difference. And actually, I'm very cautious. So like I would do a digital scan and a PBS impression for a period of time just to have all bases covered. Last thing I want to do with my patients and just my commitment to quality is to have to bring someone back. So we would do both. We noticed a little discrepancy since, you know, old habits die hard. We always kind of relied on what we know works, which is the PBS impression. But we started to slowly transition to maybe waxing up on the printed model and then comparing. And we started to find that the precision was better just in terms of how it fits visually. And then when we went fully, fully digital, I started to notice that remarkable trend where my x-rays would show a couple of things. One is no cement at the interface, because when you cement with heated composite and you do a. press technique to make your restorations, there's inevitably going to be some, you know, tolerance fit issues of, I would estimate one to 200 microns is where you end up with in these areas. And so when you start with heated composite, you see the composite on the interface and that's really not a problem. I never looked at my restorations and said, wow, my margins are not good. I just didn't know what was possible. So all of a sudden. changing nothing about how I cement or do the dentistry. I started to notice the restoration would touch the tooth structure flush. You see no cement gap there. I'm using the same composite. It just looks like there's no cement at the interface period. And what I attribute that to now that I've seen it be pretty much how it is 99% of the time or so, I think it's the precision between the scan. I'm using a 50 micron offset or dye spacer for the cement gap, I should say. And the combination of those things has resulted in that it's not the material being changed. You know, I always used to use... Emax or Lissy as my favorite. Lissy's GC's material. I always found it optically to be better. So I was using that towards the end of our days of pressing posterior restorations. That's what we left off on. But no matter what we used, I think the steps going from the impression to the model to applying dye spacer to finishing and cleaning the restoration, sandblasting, all those different things, I think they add up to create just a little less precision. of fit and it translates to that radiographic difference, which honestly caught me off guard because I was not, I never got it because I thought I had problems with margins and I still don't think I had problems with margins. I'm just so impressed of how the marginal fit has improved substantially. So one of the really cool innovations to CAD CAM is this pre-crystallized block. It's a fully crystallized block that does not need sintering. Now you use this block and you've been getting great success with it. Tell us what you like about it and how has it helped your workflow? As you mentioned, I'm using the pre -crystallized blocks now. So that's called Lissy. It's from GC. You don't have to crystallize it. So it mills and you can polish and deliver right away. Or you can stain and glaze. And I know a lot of people try to crystallize Emacs in one, you know, one bake and get all the stain and glaze in. But I really like what you see is what you get approach where when I'm staining and glazing, I want to see exactly. what it's going to look like. I'm comparing it to the shade tab. We have a pretty easy stain and glaze technique using a luster paste from GC actually, but we stain and glaze it and we can look at it and we know what it's going to look like after we fire it. We're not guessing. I always found myself guessing when I had to use Emacs in the purple state. So I was really happy when my milling machine finally supported using Lissy because for a while you couldn't do anything except the, I think it was. the Ivoclar mandrel. And then they opened it up to the universal mandrel. So all of a sudden, you know, I have a variety of options I can use. And that's been a huge time saver to be able to skip the crystallization. And I've noticed other benefits too, actually. So what are some examples of the additional benefits of Lissy Block? And how is the performance track record held up since you've started using it? Yeah, so I've been using mill restorations now for... Just about two years. I've been using Lissy for about, I would say, six months because that's when the universal mandrel became available. I think it was end of last year or January of this year. So we're going on six months, but I used to use Lissy when we were pressing. So I was just waiting for that. to come around i like the optical properties better and now that we're milling with that in addition to saving time for crystallization i'm noticing smoother margins less chipping around the margins i do oftentimes go below manufacturer recommendation for thickness at the margin because you know i'm trying to do minimally invasive dentistry i've always done that and it's always worked very well with a high adhesive bond strength so i would have chips i'd have a lot of chips when it was thinner so with emacs i had to like um do like a thicker collar and then like polish it down but now i'm not doing that and it's i think it has a lot to do with the crystal structure the smaller crystals that um lissy has in these cad cam blocks it it minimizes chipping i'm being able to mill it in the same time so like it's not like a difference in the actual mill strategy or anything and um optically i still think it's the absolute best you know i think it looks the most like enamel i never noticed that gray appearance, which, you know, e-max or lithium disilicate are so notorious for. And the time savings we mentioned is the other huge one. Not having to crystallize saves a lot of time. So someone like you, Dr. Nejad, certainly can be considered an expert in indirect dentistry. There's no question about it with your expertise. Some of the stuff that you're doing in your practice with inlays are just beautiful anatomically, and they fit very well, and it all fits into your biomimetic. culture in your practice. Now, there's still an application, of course, for many of us to do direct restorative. So what influences your judgment call to say, hey, I'm going to just do a composite resin here, direct filling, with all the phenomenal adhesive dental systems that are on the market now, we can get some really good results doing just plain composite resin, direct restorative. How do you make that distinction and say, I'm going to go one way or the other. Is it the patient? Is it patient finance? Is it time? Is it what you like? What influences you most when it comes to deciding whether or not to do indirect versus direct? So I'll try to sum that up. But basically, that's a big calculation based on enamel is a stiffer material. And when you're missing a lot of tooth structure, you're trying to recover maximum stiffness. Resin materials for large problems don't do a sufficient job. They will last five, 10 years if they're done well, maybe even longer, depending on how much energy you put into it. But when you look at the whole big picture, for me, it's not about doing direct versus indirect. for financial reasons. So my direct fee, it takes a long time to do a beautiful, high quality direct restoration. So when it's a larger restoration, sometimes the fee difference isn't significant enough. And even when presented with the options, the patients will opt for the indirect. So I always tell them what I recommend. And for me, more or less, small and medium sized problems are for direct. And as you get larger and you have to recreate more tooth structure, more of the tooth anatomy shape. You're combating polymerization, shrinkage and stress and trying to recover that stiffness. For me, the natural choice is to go indirect when things are, you know, large, medium size, all the way up to, you know, extra large restoration. So overlays, no question. Cusp coverage, I always am going to go indirect. For MOD inlays, that's one of the most common ones where I prefer an inlay versus direct. But depending on the situation, I do still do them. And I've made it fair to me for the... that I put in so that so that the fee is you know correspondingly like hour per hour the same for me so I don't really have a huge tendency to do one thing or the other but I will say I really think this is the category of dentistry that most dentists will benefit from where 3D printing may revolutionize our ability to do 3D printed, you know, you call them indirect restorations, but 3D printed fillings and basically eliminating that need to struggle with contour, proximal contacts, anatomy. When we can 3D print that in the same appointment, get all those huge benefits, it's right around the corner. So I see that and I'm preparing for that type of thing. And the same skills that go into designing anatomy on indirects are going to apply to that. So I think we're going to have a transition in that in the next few years. But to answer your question, small and medium-sized restorations, MODO, occlusal, pit and fissure, class fives, all direct. But when it starts to get larger, MOD being a big cutoff point for me, I definitely favor indirect. And someone with your skill set, I think for sure, you even mentioned it just now, that you could do an indirect restoration probably faster and more efficiently and more effectively than doing a direct restore. Not that you're not good at putting in composite. you know squirting and composite into a cavity but when you master the skills and have the setup and the and the workflow that you do day in and day out for you to knock off one of these inlays is not a big deal whereas for some for some dentists that don't do this kind of dentistry you know they're sticking to using direct restorative because that's what they've been doing all their life um their career and it's just easier to that that has a big uh effect on your judgment call when it comes time to which way to go um for sure yeah yeah i want to say one more thing like I would say, honestly, even though I'm good at doing, I do directs for anterior, so even though I'm good at doing the anatomy and everything for it, I find it to be the most fatiguing part. uh dentistry actually by the time you've gotten to the point where it's time to build up the anatomy if you care to do the level of anatomy reproduction and detail that i'm doing with enamel and dentin and having like you know staining staining glaze in the grooves or just at least anatomical grooves and everything i i get the most fatigue at that point in the appointment you know everything's going fine i get to that point i wouldn't say i struggle with it but i find myself just emotionally and mentally drained at the end of a large direct restoration or an MOD restoration. So that has an impact on it too, especially when I don't think it's a superior option to begin with. So this always basically into my decision making, but for some people, it's their best option because of lab costs, same day appointment, not wanting to rely on a lab to give you average quality lab work. So there is reasons, but in my situation and with all other things controlled, I don't see the reason to. do that for larger restorations. So before we end this podcast, Dr. Najat, I just wanted to know what your response would be. If a dentist asked you, why should I go purchase... at this point, a CAD CAM milling machine system in my practice when 3D printing is evolving so quickly with the hopes that the 3D printing setup will be able to print indirect restorations quickly, inexpensively, and at the level with what we're getting from CAD CAM. Is that a reasonable way of thinking for Dennis right now? I think that that possibility is there, but it's not for certain. And I don't want to be the pioneer doing that type of restoration. in a high quality setting. For lower and budget options, I think it makes a lot of sense for opening up access to care. But I want to see some long term. We're seeing the materials getting better and better. And I'm going to use it. I guess I'm very confident to say I'm going to use it to replace direct restorations because I only see benefits, minimizing polymerization, shrinkage and stress, having a monolithic block of material, no voids, good contour, all those types of things. But when comparing to a ceramic indirect restoration, that with proper bonding protocols has over 93%, you know, 10-year success rate. We've seen early generations of printed materials having issues with, you know, holding their shine or the glaze. And, you know, we're still perfecting those things. Not to say I'm not the biggest fan. I'm a huge supporter of those things. But I think it makes sense as a replacement for direct restorations before it makes sense for a replacement for indirect. It may get there and it may blow it out. of the water and I see that possibility. But at this moment, like for me, I don't want to be that experimental on what I'm doing. So I don't want to go there. I want to make sure that I minimize complications or redos or anything like that over the, you know, the near term five or 10 years. Yeah, that makes total sense. Great discussion, Dr. Nejad. I'm going to let you go because I know how busy you are today and you fit us in. Really good insight. You do some fantastic work. Again, I recommend to our audience to check out Dr. Nejad. webinar on VivaLearning.com. It was very well done, covers a whole lot of processes and steps and the way he thinks when he does these procedures and how he attains the real high-end quality dentistry that he's putting out in his practice. So it's a great mentor. And again, we're very happy to have you. Thank you very much for your time. Thanks for having me. Thank you so much.