Master the Social 6 with Injection Composite

Another thing I do is I don't cure all the way to like 20 seconds right off the bat. I cure maybe 10 seconds just to get it hard enough. I will peel off my clear matrix and then I will take a very sharp 12 blade, clean off the excess around the gingival area and the interproximal area, and then I will have my assistant finish the cure. Welcome to Austin, Texas, and welcome to the Dr. Phil Klein Dental Podcast. If the thought of hand sculpting composite in the anterior social six makes you break into a cold sweat, you're not alone. For many GPs, creating natural-looking aesthetic restorations in this highly visible area can be one of the most technique-sensitive, and for some of us, stressful procedures in practice. But what if there was a way to consistently produce beautiful, highly aesthetic results that make you look like a composite artist? And you can do it in typically half the time it would normally take you to do it freehand. In this episode, we're diving into the injection composite technique, a digital workflow that's helping dentists create predictable, lifelike restorations without relying solely on advanced freehand sculpting skills. Our guest is Dr. Mackenzie Kelly. a cosmetic dentist, educator, and adjunct faculty member at Indiana University School of Dentistry. She'll explain why this technique has become one of her go-to solutions for anterior composite dentistry, the clinical steps that's involved, the materials she trusts for outstanding aesthetic outcomes, and how to determine when the injection composite technique is the right choice versus a traditional freehand approach. Best of all, Dr. Kelly walks us through the entire process step-by-step, from planning the case and fabricating the matrix to delivering a restoration that looks like it was created by an experienced composite artist. So if you've been avoiding aesthetic anterior composite cases because you don't love hand sculpting, this episode could completely change the way you practice direct restorative cosmetic dentistry. Before we get started, I'd like to thank all of you for tuning in. If you're enjoying the show, please follow us on Apple Podcasts and Spotify, and even better, leave a review. By doing so, you're not only showing support for what we do here, but your reviews are instrumental in getting more dental professionals to listen and benefit from our content. We really do appreciate it. Dr. Kelly, it's a pleasure to have you on the show. Great to be here. I'm really excited. Thank you for having me. Yeah, so you often describe composite as an artistic medium. What is it about working with composite that you find so rewarding? And why do you think it offers a kind of unique level of creativity compared to other cosmetic procedures? Well, a lot of us dentists got into the field because we like working with our hands. And with composite, you can... an immediate transformation so to speak you know i use other mediums to transform people's smiles as well i use porcelain veneers but then you're relying on a lab to do what you're envisioning in your head composite allows me to envision what i want to do and you know kind of use my hands to create this amazing before and after procedure. I can actually use my brain, get creative and do a transformation right there on the spot. Now, just curious. And I remember dental school, it was a while ago, but I do remember dental school. And there were those individuals, those students in dental school that were really talented. They could wax up from a block. you know a beautiful tooth were you one of those students that artistically just had it you caught me yes yeah so that was me i loved waxing i actually got paid by my school to do waxing for actual patients so i have always loved waxing it's just been a natural talent for me yeah i mean that's that's a great gift I went into endodontics, so you're probably thinking I probably wasn't one of those people that were super artistic. But I got by, but I would never even dream of putting my wax up next to yours. And I don't know you, and I haven't seen your wax ups, but that's my guess. Sure. So talking about artistic ability, one of the biggest obstacles, I think, for many GPs is confidence in their artistic sculpting ability. But in recent years, one particular procedure is becoming more and more popular and really a viable option to freehand sculpting and that's injection composite technique or what is sometimes referred to i've heard it referred to as injection composite molding but i like injection composite technique better so before i hand over the mic to you dr kelly with some questions i briefly want to give our audience a quick overview of this procedure so injection composite technique uses a clear custom-made template created from a diagnostic wax-up. And assuming in digital workflow, that diagnostic wax-up can be designed and fabricated at the lab or directly in the office. And from that, a template is made. And that template is used as a guide for the placement of composite directly onto the tooth. So instead of sculpting the entire restoration by hand, which I know you could do, the dentist injects the composite through small openings in the template. allowing the material to flow into the exact shape that was planned in advance via the diagnostic wax up and then of course once the composite is cured the templates removed and only minimal finishing and polishing are typically needed now i know there's a lot of details in between there as far as you know teflon tape and technique and we're going to ask you to go over that with us so having given that Is that correct, by the way? Am I on target? That's perfect. You're on target. Okay, good. For an endodontist, I'm happy. Sounds like you could do it. Yeah, yeah. Well, for the few composites that I did do in my career, I wish I had this technique. So with your experience, if a GP is wondering when to reach for the injection composite technique, what cases would you say are ideal? And can we make our composite restorative cases not only more beautiful using this technique, but also more efficient? with our chair side time i think you can use it in most situations honestly there's not a situation that i can really think of where you would do it freehand and you couldn't also use injection composite in that exact same scenario. You know, it's always hard to mask a dark tooth, but that's going to be the same whether you do it with injection composite or whether you do it freehand. Sometimes larger diastemas can be a little tricky with injection composite. I find that doing a diagnostic wax up with every other tooth really, really helps. toward the interproximal areas because I think that that's where some dentists can run into trouble. But I use it anytime I am wanting to get very detailed specific anatomy. I use it anytime I'm trying to add length or close diastomas. And if a patient is wanting something very specific with regards to maybe a certain translucency or characterization, you can always use your initial injection composite and then do a cutback technique and layer in additional composite, but you still have your overall shape, which I think is what most dentists feel the least confident with. Now, let me ask you this. There needs to be some preparation for these. direct composites where it's different than what we typically did in the past where the patient came in and you did maybe some preparation on the tooth and then you went right in with your direct composite in hand. crafted it so to speak but now you're using this clear template so tell us about the preparation difference and treatment planning and how do you you know how do you plan that your team is ready for this and when the patient sits down you're ready to go So I do my own digital wax ups. So I'm lucky in that regard. I love digital technology. I use Exocad. I learned to do Exocad from taking one of Diana Tadros's courses. I'm a huge fan of hers. That's where I learned my knowledge. And so I will do my own wax ups and I will wax up the ideal design. And then when I'm going to create a model, there are some different ways that you can go about within the Exacad software where you can actually design a model. using every other tooth and then you can print one with every single tooth and then when you're making your clear matrix you also want to make two different clear matrices as well you want to make one with every other tooth and that's going to really help you control the contours of the inner proximal areas and then you're going to make a second clear matrix for the every tooth situation so it's really important i've you know sometimes had a quicker on the spot injection composite case where I didn't have time to do the every other tooth print. And there's a lot more cleanup to do afterwards, I will say. So it does reward you in the end if you take that time planning the case well. What about using Teflon tape and using just one template? So yes, I even, you could, and I actually did a case this week doing it that way. I will Teflon every other tooth. I will AeroBraid the exposed teeth in order to increase my bond strength. I love AeroBrasion. And then I will complete every other tooth. You never want to do multiple back-to-back teeth at once. It's just kind of a... headache in terms of cleanup right so if you're using one template and you use teflon tape you do every other tooth and then correct then you come back you clean all that up and then you teflon tape the teeth that you just restored and then do the other remaining teeth correct and i found it to be really helpful so this week i actually had that situation where i just printed one model and had one clear matrix and I Teflon taped every other tooth and I did six through 11. So six teeth, but I did, I don't know, six and then eight and then 10. And I made sure to finish and polish all the way to completion because I find that if you're only going to use one model and one clear matrix, if you finish and polish, you'll have. less cleanup, like less composite will adhere to that really shiny polished composite tooth that you just did. So if you're going to use one model, that's one shortcut. I would make sure to get it all the way almost to darn near completion before you go in and do your second set of teeth. Oh, that's an interesting tip. So from the digital workflow side, tell us how you use your digital equipment from the time you scan the patient. to the time that you actually have two clear templates in your hand. How does that whole process go? And then we'll get into the clinical chair side stuff. So I will meet the patient. I'll get to know them a little bit better. My assistant will take a great set of photos on them using a nice camera and we'll make sure to get a really, really good full face photo. I think that's very, very important. You want to make sure that the patient is in natural head position and they don't have their head tilted to any side. And then I will have my assistant take a digital scan of them as well. And then I, within the Exicad software, will merge those files and design what I think would look nice on the patient. And then, of course, I will print that model. So that's kind of the... on the back end, I typically won't meet the person and do a consult and do the same day treatment. I do have some patients travel in to see me and I would always prefer they come in in the evening and then I do the procedure the next morning, even if they're traveling from a distance, because I just really think you got to spend the time planning out the case and printing the model. It just makes such a difference. Now, when you print that model and you show it to them, is that used as a sales? tool for them to be educated and say hey this is what we think your teeth can look like and we're talking about the social six or the social four and we're talking about veneers primarily Absolutely. I think that it is the best way to get case acceptance. I like doing mock-ups on everything, even if I'm doing little composite edge bonding or if I'm doing a full mouth of porcelain veneers. I think it's really, really important. And I will know, I know we're going to jump to the clinical aspect before I do any type of injection composite. I think it's very, very important to try the mock-up in their face. You don't want to spend all the time. the teeth and doing Teflon and isolating and only to find out that when you're done with your finished product, they're not really the length that you want them to be. So I think it's also worth it to make a clear matrix, but also make some sort of putty matrix and do a traditional mock -up. Yeah, provisional mock-up. So what do you use something like Luxotemp or something for that? Correct. Yes. Now, do you get them to sign off on that when you make that provisional using a putty matrix? So you have the clear template to inject into for the final. But before that, you're showing them the model. They're kind of sold. Even if they accept the model, the digital wax up from the model that you printed, you still go to a provisional? So yeah, I will use that to guide because maybe I want to know for myself, it's a selling point, but I want to know whether or not it looks good. In the patient's mouth. In the patient's mouth. Yeah, it looked good in my digital software, but maybe the head was tilted a little bit when we took the picture. So I want to check before I ever get them numb, before I put a handpiece or any etch to their mouth. I want to make sure it actually looks good in their mouth because at that point still. it's reversible. And I think it's really important too, if you have teeth that aren't in the correct position or you have a tooth that's darker, if you use some sort of provisional bisacryl material first, you can see if the tooth is showing through and that helps guide me what type of a composite am I going to need to use for this case in order to mask that. Yeah. So let me ask you this. What would you say to a dentist that said, hey, you're doing a digital wax up. You're showing the case to the patient and they're getting sold on it. Now you're making a provisional using a putty matrix, but you're also doing a direct injection with the template. Why not just do veneers using lithium disilicate other than cost? Well, sometimes the teeth are not in the right position and you still have to have some sort of path of draw. The beauty of composite is it could be 0.1 millimeters in one spot and a full millimeter of thickness in the other spot. And so the beauty of composite is that you have varying degrees of thickness and you can still get a beautiful product. Tons of patients come in now wanting totally prepless veneers or minimal prep veneers. And the reality is, unless they have small teeth, not all of them are candidates for totally prepless cases or minimal prep cases. Even if they do some sort of ortho, you know, you have to prep them a little bit. And so I just like the flexibility and the versatility of using composite in a lot of these cases because you don't have to worry about path of draw issues. What about longevity? though if i said there's no composite that's going to last as long as lithium disilicate now are you using a material a composite that you have enough confidence in that you feel you can go years with it yeah so i've heard that time and time again and so I really, really like the VOCO Grandioso For You products or the Grandioso Flow because they have such a higher filler content. That's what makes me a lot more confident with the product because I know the higher the filler content, there is a higher strength. And if there's a higher filler content, then there's less resin. And the resin components of the composite are the part that we don't necessarily want. That's what picks. up stain and that's what has a shrinkage. So I know that if I use a higher filler content, I feel a lot more confident that the longevity is going to be very, very good. I think that the porcelain veneer is always going to be gold standard, but I feel very confident that my composite restorations are going to last a long time because I use good quality materials. So you're fabricating these veneers without a lab. essentially. You're using composite. You still have some steps though. So until you get really comfortable with this method, it does take some chair side time. Do you feel like you're charging the patient commensurately based on your chair side time, even though you don't have the lab fees? In my opinion, yes. I charge half my fee. So I have a certain fee for my porcelain and I have half that fee for composite restorations. You don't necessarily have any lab fees because you're an Exocad genius, which a lot of dentists are not. I mean, Exocad has an unbelievable number of features. But generally speaking, most dentists want to send the design work out to the lab to do, and they don't want to get involved with it, especially with software like Exocad, which is fairly complex and comprehensive. Sure. And I feel like it's really one of those things that you have to force yourself to practice. I've heard of dentists buying the equipment and then not using it, which is just a huge waste. I don't know, a missed opportunity because I use it every single day. It honestly, I know I'm a younger dentist, but it brought joy back to dentistry for me because at my heart, I'm an artist. I love creating. And so it allowed me to start creating again. Have you used analog techniques before you jumped into digital in your practice? Not in dental school, but in practice. I had. I didn't own an actual wax kit, but what I would do is I would take an alginate, I would pour up a model, and then I would wax, but just with flowable composite. And then I would trim it away and do something like that. And then I can still make some sort of clear matrix with that or like a lingual shelf or something. So you have the versatility of being analog and digital, and plus you have the artistic ability. So the sky's the limit with you, Dr. Kelly. There's no question about it. So getting back to the actual injection composite technique, tell us about the materials, the matrix, and then go into the clinical steps. So typically I will use some sort of... clear PVS type material. And I will tell you right away, my strong suit is my artistic ability. And I will admit, I am not a genius when it comes to dental materials. I know what works in my hands. But if I'm misspeaking, I apologize. Generally, I'm genuinely trying my best. So I'll use some sort of clear matrix material because it's flexible. I personally like Kettenbach Future Clear. I think it's a great material. I am going to admit, I don't always put it in a pressure pot. A lot of dentists do. I think it makes the material more clear. And if I have time, I will certainly do that. But the material works great, even if you don't pressurize it. And then I have found a really helpful tip is when you're creating your small little points into get your composite, I will take a... resin tip and I will go into my lab and sharpen it so that I can pierce it really sharply. And it won't have all the little tissue tags running through the clear matrix. I didn't used to know that tip and I would go in there with a burr and it would just create almost like this shrapnel within the clear matrix. And then you had a really difficult time trying to guide your resin tip back through. So I will spend the time and pier and make my tips really pointy. And so I'll create little channels. And if it is a larger tooth surface, I actually use this quite a bit in the posterior as well to build up someone's occlusion. So I won't go there right now. But if it's a larger occlusal surface, I'll actually put two different ports in so that I can... So just so it's clear to our audience that may not have ever done this procedure, you're talking about the ports that allow you to inject the material into the actual... clear matrix once it's seated right once it's fully seated so correct once you have that clear matrix before you i guess you try it in first to make sure that it fits how do you prepare the tooth the actual tooth and talk about the tooth is it all enamel is that what we're working with basically yes so i'm doing these procedures pretty much all enamel. I am a lot more confident with my enamel bonds. And then we talked about durability. I know that enamel bonds is one of the strongest bond bond strengths there is. So I feel a lot more confident with the strength and longevity of the restoration. If I can get it a hundred percent within enamel. So I'm not preparing the tooth surface with any sort of hand piece, but I am doing a form of like micro preparation with an air abrasion unit. I use the KAVO unit. It's wonderful. And then I will isolate every other tooth with Teflon tape. And then I will spend time using a phosphoric etch on the tooth surface. I'll let it sit because it's unprepped enamel. So I'll let it sit for about 30 to 60 seconds. I'll rinse and dry, make sure that my assistant doesn't suck up my Teflon tape. hit or miss with that sometimes. And then I will apply my adhesive. What kind of adhesive? I love VOCO Futura Bond because it is self-etched. So I know maybe there's an area of dentin that could be exposed. I know it's going to etch the dentin surface really well if there is a small little area of dentin exposure. Yeah, these universal bonding agents are really good because they work with selective etch. They work with total etch. Yep. So when you don't reduce the teeth how often do you get over contouring because the thickness of the composite has to be you know something it can't be so thin that when they bite on something it just chips off do you find sometimes that you have an over contour tooth where you have to kind of take it back and then you're risking having too thin of a layer of composite sure i think it's really important to squeeze your clear matrix really well i didn't used to do that i didn't realize how important that was i would kind of just put my resin within the port and just squeeze and it would go everywhere, all over the gingival surface, all over the adjacent tooth. My Teflon is blocking that adjacent tooth, of course, but still it would create a lot of cleanup. Now, before I cure, I squeeze the adjacent teeth areas pretty well. And then my assistant will use a curing light. Another thing I do is I don't cure all the way. to like 20 seconds right off the bat. I cure maybe 10 seconds just to get it hard enough. I will peel off my clear matrix and then I will take a very sharp 12 blade clean off the excess around the gingival area and the interproximal area and then I will have my assistant finish the cure you have to be careful with doing this because if you're not using a really sharp 12 blade you could accidentally take away a huge chunk of composite and then you're kind of left with free handing to replace that missing area so I find if you squeeze the clear matrix pretty well, it kind of minimizes that excess and you don't have extra like overly contoured composite everywhere. So regarding case selection, you know, this is an aesthetic procedure, no question. Sure. And you're probably treating a lot of patients that have wear facets, that have discolored teeth. These patients may be older and they have the typical chipped teeth, heavily worn, yellowed. When you do this procedure and then they look in the mirror after you're done, they must be like wowed to death. I mean, it must be just such an exciting thing for them to see their teeth come alive like that. They love it. They love it. It's such a cool experience seeing it when they're just standing up in the mirror and looking and they just can't believe that that was possible. So it's a really, really cool moment. And what's the chairside time we're talking about for like the social six, let's say? It takes me about still about three hours to do two and a half hours. Um, it depends if I'm going to have to do any sort of cutback technique. It depends if their gingiva is healthy. I mean, if they have healthy gingiva and you're sitting there and flossing and it doesn't stimulate bleeding, that is half the battle because when you're cleaning out all that Teflon tape in between the tooth and you're having to floss a lot to get it out, then if there are any type of unhealthy, I mean, you're just asking yourself for, a not fun experience in terms of finishing. Do you use a hemostatic agent prior to all of this? I do. I use like a clear hemodent type situation. Okay. Or a paste maybe? Yes. Like a retraction paste. Yeah. Or I'll use a retraction cord that is not soaked. I'll just push it back and use pressure as a way of hemostasis. So what about isolation? So I really like the Opturgate. I think it's a great product. That's by Ivoclar. Yes. Very good product. Wonderful. That's my favorite. I love that. It's a wonderful way. I find I use rubber dam isolation for other composite techniques because I don't just do injection composite. I do other composite techniques as well. But for this, I just find that you... the rubber dam gets in the way it's like i don't care what you say it gets in my way anyway it's interesting because you know as an endodontist of course and i've said this to the audience many times you know we have to use a rubber dam and we want to because it's it's easier and endodontics is you know endodontics you you go through the occlusal you don't have to really do a lot in approximately um and you certainly don't want anything to fall down the patient's throat but the more i talk to restorative dentists. And some of these people that I talked to were department chairmen at dental schools of restorative dentistry for 20 years. And they use things like, you know, Opturgate and they use Dry Shield or they use different things. But, you know, half of them or less than half use rubber dam. They just, I think it really depends on what you're comfortable with and how good you are at putting a rubber dam on. There's a skill to it. I've finished a case before where I've dammed everything. And then I, not doing injection composite, just doing more freehand, like a composite veneer. And I've finished and I don't really like the length. And that hurts when you have spent so much time layering all this composite and then you don't really like the way that it looks. Of course, like I tried to plan my best and do a mock-up beforehand to make confirm length and confirm aesthetics. feel like so you're saying the rubber dam took away your visibility yes aesthetic visibility of the whole picture Yeah, I lost my perception of where things should go in relation to the lip. And that's everything for me. So sometimes I finish with my rubber dam cases and I'm like, oh, I'm going to adjust that length a little bit. Whereas if I'm just using the OptraGate, then I can take it in and out and I can keep checking while the patient's smiling. And I really like working on patients when they're not numb. And I find that sometimes with some of the rubber dam clamps, they're a little uncomfortable. So it seems to me, Dr. Kelly, that if a dentist is in the digital workflow and they have a scanner, which I think every dentist should by now, they have a printer, which they don't necessarily need for this, but they should have it. There's a huge savings of time over freehand sculpting of composites. It's a great alternative to fabricating lab indirect restorations through lithium disilicate. I mean, you're going to save the patient money. But you're also going to get like immediate gratification from the patient based on how fast you can deliver these. It's a win-win for the patient and the practice. I don't really see any downside to this. Gosh, it's so nice. And now all of a sudden you can do composite work and you can do it a lot faster and more efficiently and more predictably. And that's the huge... a selling point for composite for me, especially injection composite, because you can do beautiful work in half the time. And I think that there's always going to be a time and place for layered technique and doing it that way as well. But a lot of dentists don't want to spend the time doing it. They say, oh, I can do another quadrant of dentistry in half the time and make more money. And we all want to help people, but there's a business to dentistry. And I get that. So this allows us to be a lot more and still get a really amazing product. Yeah, and using the right composite, I know you like VOCO's Grandioso for you. And that 91% filler content is really revolutionary. I mean, because- It is. Yeah, no other composite has ever had that kind of capacity to put that much glass in there and other filler particles and also have the handling characteristics that it has. As soon as someone hears 91%, they're thinking this thing is as stiff as a board. I'm not gonna be able to work with it. so the grandioso for you has like the the extremely high filler content it's just made with the packable right now. But the Grandioso flow also has an extremely high filler content, 81%. Whereas all other flowables right now are like in the 60s and 70s. Yeah. So I just feel really confident, even though I'm using a flowable, which quote unquote, you would think is not that strong. I feel confident using it in this situation. And I think it's going to give a really great long-term solution for the patient. percent flowables is still outrageous. So as we wrap up this one, after listening to this episode, if every dentist remembered just one thing about injection composite and direct aesthetic dentistry, what would you hope that takeaway would be? I hope that they spend the time planning and preparing on the front end because I truly think that can make or break the first experience. If you have a bad experience the first time, you're not going to want to do it again. Give yourself enough time so that you have ample time to sit there and isolate appropriately with Teflon tape. Make sure you have two different models printed out. Even if you're using a lab and they're designing your case, it's worth it to spend the extra money and print out two different model variations because it will make your life so much easier on the back end. And then once you prepare and you've planned well, it's really just fun because then you inject and then you peel off your clear matrix and you have this beautiful result. It's almost, you're going to do it for the first time and be amazed at how good it actually works. It's really fun. You think you're as excited as the patient is when they see it every time. Oh yeah. I mean, I'm so excited. I'm going up, I'm hogging the mirror with them. I want to see. So, you know, your enthusiasm is certainly contagious. I think it's amazing that you're a young dentist. You're in a field that you really love. You found a way to do something that makes patients incredibly happy. And it's not all about the money. The satisfaction you're getting from practicing dentistry is worth far more than any dollar amount you could put on it. Thank you so much, Dr. Kelly, for all this great clinical information. You packed a 30-minute episode with a lot of clinical pearls. And I wish you the best of luck with your continuation of your practice. And we hope to have you on the show again soon. Thank you so much. I really, really enjoyed it. This was a lot of fun.