Restorative Pearls: The Key to a Great First Impression

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing indirect restorative dentistry and the principles for achieving a perfect impression. Our guest is Dr. Chad Duplantis, a practicing dentist and Academy of General Dentistry fellow. Dr. Duplantis, it's a pleasure to have you on Dental Talk. It's a real honor to be here, Dr. Klein. Always good to chat with you. thanks for coming on i know how busy you are just to spend a little time with us today would be great because we're talking about some very important topics about getting a really good impression which we all need to do when it comes to impression taking we often hear contrasting opinions on digital versus analog in your mind is one better than the other for indirect restorative dentistry You know, I think it's all a matter of personal preference. We know that more and more dentists are adopting digital technology within their practice, and we do know that digital technology is now very, very accurate. There is not necessarily one's better than the other. It's really what you're more comfortable with, and I would say that we're at a level of accuracy where there's no reason to not adopt digital technology into your practice. i think that you're going to get great results either way as long as you adhere to the principles of impressioning so how long do you think it'll take for the laboratories to like say hey you know what we don't do traditional materials anymore we're strictly a digital lab is that going to happen anytime soon I don't know. I think the most recent number I've seen is close to 50% of the dentists have adopted digital impressioning into their practices. So I think that number is going to have to be much higher because if a lab does that at this point in time, they're going to shut down a lot of business. So I think we're still a ways from that. But I do think that a lot of labs are starting to encourage docs to incorporate digital impressioning systems into their practice. Yeah, and of course you can use as a dentist a hybrid approach, right? Some of the cases could be analog and some can be digital. Absolutely. Some doctors want to use digital for their same-day restorations. Some doctors want to use it for just single-unit indirect dentistry, maybe bridges occasionally, but they're still going to take traditional impressions for the more demanding cases. I still take traditional impressions for all of my removable dentures. I use digital for partials, but for removable dentures, full arch dentures, and a lot of my full arch implant cases, I'm taking analog impressions. So there is a hybrid approach, absolutely. So for restorative dentistry, what are the principles for achieving a perfect impression? If we can use the word perfect, nothing's perfect, but as close to perfect as possible. What are those principles that you adhere to in your practice to reach the highest level you can get? i think it all starts with a really good prep i mean that's that's the key you know you have to prep as close to ideal as possible i always say this that ultimately carries and previous restorations are going to dictate the final nature of our preparation but if we keep sound principles in mind you know make sure that we have great margins uh make sure that we have you know almost parallel walls you know four to six degrees of convergence or taper on the walls. Make sure that we have good axial wall height when we can. That's where it all starts. But beyond that, once you've achieved that good preparation or as best as you possibly can, you have to be able to visualize your preparation in a mirror. You have to be able to retract the tissues so that you can visualize and properly capture those margins and you have to be able to control the moisture the blood and saliva around that preparation so visualization retraction and moisture control are key once you've got that great preparation right and that's well said so isolation is a big factor but this podcast is not going to really talk too much about isolation although that's really important right is to isolate what you're doing the best you can and there's various devices for that and so forth but retraction is part of that isolation in some ways, right? You need to move that tissue away so you can make those margins available for either a digital or analog impression. So tell us about retraction. What do you recommend? What are some of the things you're using in your office and doing in your office to help you with a really successful retraction process? Sure. I think that, you know, the ultimate goal is to achieve super gingival or... closely approximated to the gingival level margins but that's not always possible so you're always gonna you're often i should say gonna have margins that are subgingival and you know one of the things that's worked really well in my practice is i like to use just a single cord that's soaked in some sort of astringent material that I place into the preparation. And then on top of that, I'll place a retraction paste. And the retraction paste is really key because it does provide an ample level of retraction. And it also controls the sulcular bleeding that can occur following preparation and prior to impression as well. Cord and paste is usually my go-to. And in certain instances, I find that these newer pastes are all that you need if your margin's not terribly subgingival. Yeah. Can you tell us about some of these newer retraction materials? And I know Voco has one. I think it's called Retraction Paste, not the most original name ever. Talk about the different options the dentist has as far as paste. And I know some of the old paste from back in the day where they were hard to extrude. you know, there were some disadvantages to them. So what innovations have come out where they're improved at this point? Yeah. So, you know, it's funny that you say that it's a horrible name. Ask many dentists. I think that we all think it's a fantastic name because for once we have a product that actually is named for exactly what it does. You know, it doesn't have this funky long name with these code words and whatnot in there. So I think it's an excellent name. Over the years, retraction pastes have changed somewhat over the past several years. But what Voco did that's really unique is they made this product to where it has a dual phase consistency. So when you first inject the paste, it actually flows into the sulcus quite nicely. And then it hardens over time. And that's what really... I say hardens. It doesn't ever really get to a consistency where it would be brittle or whatnot. But it does become more viscous, I should say, over time. It's aluminum chloride based, which is great for the astringent capabilities. But I think the dual phase consistency is really, really unique, which is something that I haven't really seen from the other manufacturers in the past. The other thing that's really nice about... this retraction paste and i could say this for some of the others as well but what i really like is the the cleansability of this it's highly visible when it's placed and then it rinses right off which leaves you with crisp dry visual margins and you're not having to deal with this excess paste that you're going to worry is going to affect either your analog impression or throw some artifact in there for your digital impression so you're saying that because it has a lower viscosity from the onset it's easier to extrude into the sulcus extremely easy to extrude into the sulcus and that's the big differentiator from this paste from paste of the past? Yeah, you know, that's one of the differentiators. And I guess one of the things that I failed to mention was that it has a really nice tip that will actually fit directly into the sulcus. And so you've got the tip that fits in the sulcus, the easy flow upon delivery, and then that second phase where it actually becomes more viscous and expands the sulcus. So it's really nice and easy to use, and it does the trick very well. And it's delivered through a custom gun? You can use any composite gun. It's very similar to a composite compule with just a nice, long, extended, thin, flexible tip that allows you to place it into the sulcus real easily. So you still use single cord with the paste. Is it possible? Yeah, and you did mention cases where you wouldn't have to, but... heard in the past with this particular paste that the doctor just goes in there with this paste and doesn't use cord. Is that something you... Right. Yeah, go ahead. That was the hardest thing for me to actually, you know, you can't teach an old dog new tricks. And so I had done it that way for so many years that I figured, okay, well, I'm going to see how it works without the cord. I'm still a creature of habit. So on my... So my margins that are more subgingival, I will still pack the cord, but I have used this without packing any cord, and I still get nice, clean, visible margins. This is actually a pretty big breakthrough in the category of retraction paste. I would say so. I would say so. I really like it, and a lot of the other docs that I've talked to that have tried it really seem to like it as well. Yeah, good to hear. Okay, so any other tips clinically that you could recommend to our audience about using retraction paste, in this case vocal retraction paste, digital versus analog, anything to look out for, any caveats that might be very useful as a clinical tip to our audience? You know, before I started using retraction paste, I noticed a lot of sulcular bleeding, and even when you pack cord, you're still going to get that sulcular bleeding. My recommendation is really try a retraction paste, because if you pack cord and you're still getting sulcular bleeding, I promise you this retraction paste is going to stop it. I mean, this has been really, really nice at controlling sulcular hemorrhage, and I've seen... results from it. You know, and a lot of doctors just don't want to pack cord and that's okay as well. Like I said, I'm a creature of habit. I've packed cord for... for uh several years now and um you know it's hard to get away from it but if you don't like packing cord and you're still having issues with your lab or yourself not being able to visualize your margins try a retraction paste you know let especially one that's got the two-phase consistency and see how it works and if it changes the quality of impressions that you're taking yeah no that's all good good input and i appreciate that Dr. Duplantis, I think the big thing is, is that in the past, when retraction paste was marketed to the dental profession, you know, it was the next best thing since sliced bread. But when they started extruding it, they realized, you know, this is harder than using cord. This stuff just is like a bear to get out of the dispenser. And it wasn't worth it. It just, it was like a clay. It was very, very dense. I'm a retired endodontist, so I'm just kind of repeating what I've heard. So correct me if I'm wrong. But yeah, so that's really where I think the innovation is. And I think if it's not a laborious task to extrude this stuff and that phase change gives you the, like you said, the viscosity that you're looking for to retract the tissue, to muscle that tissue away, then it's certainly worth looking into. And that's why it's always good to hear from doctors like you who you are an evaluator, right? A product evaluator too? I am. Yes, yes, yes. Yeah. So that's really important to be. a wet finger dentist, someone who's in the mouth, treating patients and also evaluating products. And you also advise some of these companies on how to revise their products, right? I do. I do. And, you know, it's funny. I think that the retraction paste of the past, you hit the nail right on the head, is that I don't know that they were really retraction paste. I think they were more astringent clays. You use this like molding clay almost, and it worked really well at stopping the circular bleeding, but you got almost zero retraction because of the delivery and of the consistency. It would have never fit through the tip. that they've recently released on this new retraction paste. And so it finally does exactly what it says, and it controls the bleeding very well also. Yeah, and as usual, VOCO's leading the curve on a lot of these products. They're a super -focused R&D company out of Germany, and they know what they're doing. They listen to KOLs like you, and they use that feedback and feed it into their intellectual property and come out with products that are actually useful to the practitioner. Dr. Duplantis, it's been great talking to you as usual, and we look forward to having you on podcasts going forward. I'd be honored to be back. Thank you so much, Dr. Klein.