Is this the death of composite layering and the tedious cusp-by-cusp build up? This episode might just change how you place posterior composites for good!

I know so many of us have reservations about bulk fill composites – when I was exposed to the Fast Modelling technique in 2016 I had too many doubts. All those doubts were cleared in this 90 minute episode – grab your onions Protruserati!

Joined by Dr. Ahmed Tadfi, we explored this innovative approach that promises increased efficiency without compromising on quality. We delve into the details of the fast modeling or the ‘Espresso’ technique, its benefits, and how it can transform your practice. Whether you’re seeking greater efficiency or curious about new techniques, this is your guide to elevating your posterior composite restorations

https://youtu.be/YXJ6oW6qUKU Watch PDP177 on YouTubeProtrusive Dental Pearl: Composite does not like to be dragged – consider using composite brushes or a cutting action, as opposed to a dragging action, especially if using the Fast Modelling Bulk Technique.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

04:26 Protrusive Dental Pearl – Composite Handling

06:07 Protrusive Guidance Platform

09:24 The Journey of Dr. Ahmed Tadfi

17:44 Ahmed’s Struggle with Posterior Composites

27:46 Help Save Nafisa’s Life

30:03 Evolution of Espresso Technique

31:30 Importance of Proper Cavity Design

33:01 Step 1 – Pre-Operative and Caries Removal

40:03 Step 2 – Pre-Wedging, Matrixing, and Final Clean 

46:04 Step 3 – Etch and Bond

58:51 Step 4 – Final Adhesive Layer

01:01:21 Step 5 – Managing Marginal Ridge

01:08:18 Step 6 – Restoration Process

01:15:00 Clarifying Use of Microbrush to close the fissures

01:16:02 Step 7 – Restoration Process Continued

01:19:03 Step 8 – Glycerine Application and Polishing

01:21:07 Step 9 – Occlusion Check

01:24:56 Learn more from Ahmed Tadfi

01:28:02 Ahmed’s Advice about Implementing the Technique

Check out Dr Tadfi’s Composite Artistry courses

Join the Nicest and Geekiest Community of Dentists in the World: Protrusive Guidance – we will be able to comment and discuss on this episode and share more with each other that way. The clinical papers and Composite recommendations have been shared there.

Please do donate to Smiles for Nafisa – we are almost there to saving her life – this will be HUGE for our community to help one of our own!

If you loved this episode be sure to check out Composite Veneers vs Edge Bonding – Biomimetic Dentistry with George The Dentist – PDP075

Click below for full episode transcript: Jaz's Introduction: How are you placing your posterior composites? Are you doing like me? Are you doing cusp by cusp? Or have you discovered another technique? Well, I'm going to start by giving you a warning, Protruserati. This episode may completely change the way you place your posterior composites. I'm talking here bread and butter daily restorative dentistry.

Jaz’s Introduction

It might just completely foundationally change it to the core. And of course it’s got to be for the better. So the technique that we talk about today, the fast modeling technique or the fast modeling bulk technique, this could be an absolute game changer for you in your practice. I know I have internalized it and thanks to our chat with Ahmed Tadfi today, even now I myself am changing the way I place my posterior composites.

Because although I enjoy the cusp to cusp and getting the nice anatomy, it’s something I was taught on course many, many years ago, and I’ve just been doing it, and I’m in a good flow. I just feel that the efficiency can be a bit lacking. Doing two millimeter increments, use something called the snow plow technique, which Ahmed also uses, so I’ll let him explain that in the middle of the episode.

And whilst I’m happy with how my composites look, and thankfully post op sensitivity is not an issue in my hands. So for me to change, I’m resistant because when you have a winning formula, why should you change? But the number one reason I will be changing to this fast modeling technique, also known as the espresso technique, which you’ll hear about.

I just love it. The whole one shot concept, which will go into full detail, but the lure of it, the attractiveness of this technique is the efficiency part. And that’s what I really crave now. Look, for many of us general dentists, this is how we feed our families. This is like bread and butter, daily stuff that we do.

So there’s always a risk involved when you’re changing something foundational, such as this. And I’ve got a feeling that after listening to Dr. Ahmed Tadfi today, if you’re not already using this technique, then you’re probably going to consider changing, but if you’re already using this technique, the step by step way that we approach this episode, and how meticulous, that’s a great word to describe Dr. Ahmed Tadfi. Absolutely meticulous, man.

And the meticulous detail that we go into is really going to make it tangible. So if you’re already using this technique, it’ll give you good validation. And I’m sure you’re going to pick up a pearl or two from Ahmed. I actually remember visiting this technique hands on in a workshop in Singapore, like seven, eight years ago.

But I left that workshop, although it seemed like a good idea to me. I left with too many questions and I didn’t get the clarity I needed. So when I visited this technique again with Ahmed for this episode, it cleared those doubts I had. I just had some doubts about sealing the dentine and the c factor issue and all these things were going on my mind back then, but now they’ve truly been answered.

So now I’m ready to change this very foundational part of my dentistry. But it’s changes like these, things like these that we pick up and it actually makes our day to day dentistry more exciting. I do have to say that just because Uncle Jaz said it and Ahmed said it and he’s making a good argument, if it doesn’t make sense to you, please don’t switch this technique, okay?

And in dentistry, never change to a technique just because you read it once or you came across it through a podcast. It really has to make sense to you. So what I’ll be doing is on Protrusive Guidance, our free platform, our community platform, which also has some pay plans, but essentially the platform, the community element of it is absolutely free on there.

I’ll put together which composites you can use for this technique. Cause you can actually be doing your patient a massive disservice if you’re using the wrong type of composite for this technique. It has to be a specific composite and a clinical trial that was posted using this technique, comparing it to the cusp by cusp buildup.

So if you still need to carry out some due diligence before you change your technique. I think that’s a great thing, but I’ll make those available to you all on Protrusive Guidance. The website for that as always is protrusive.app. For this episode, which will be worth 1. 5 hours of CPE or CDE credits. So it might take a couple of commutes to digest this one, but I tell you, this is really important.

Now, if you really want to skip the foreplay and you want to go to around about halfway mark when he actually gets into the details of the step by step posterior composite part, then be my guest. But by doing that, you’re going to miss something really foundational. You’re going to miss some really important journey stuff.

How Ahmed faced a few setbacks and failures across his career, which is actually quite inspirational. But then also, if you’re going through a bad patch, then trust me, you want to hear the first half. It’ll help us to tap back into our motives and why we got into dentistry and how we’re in this wonderful profession, no matter what people say, all the doom and gloom, just to keep remembering.

We are in a really great artistic profession. I’m hoping that episodes like these ones will rekindle your passion. The entire ethos of the community and Protrusive Guidance is falling in love with dentistry again, and the nicest and geekiest dentists in the world.

Protrusive Dental Pearl

The Protrusive Dental Pearl is actually taken from this episode, but it’s so good. It needs to be emphasized again. When we’re handling composite, composite does not like to be dragged. you might remember dragging it with a probe and as you’re dragging it, kind of leaving like this thin trail of composite as you’re dragging it and it starts to look a little bit messy and maybe that increment of composite is slumping in the wrong direction and and so it’s well known that actually we shouldn’t be dragging composite which is why you see so many people using those brushes right?

I’m a big fan of the brush when I’m working anteriorly one I use by gc you get this autoclavable handle and then you get these little brush tips that you put on I know cosmodent also do some brushes so these brushes are widely available and they overcome this dragging issue, but the other way for this technique, the fast modeling technique, what you want to do, and it’ll make more sense when you get to the middle, to the end of the episode is when you’re actually doing the cut of your composite.

And when you’re listening at the end, I actually thought he meant cutting back the composite once you cured it. So I completely misinterpreted that. And then that’s why we revisited it and just made a lot more sense when you have your uncured soft composite mass and you’re making your cuts with the probe or the fissure instrument as he uses you are not to drag. Do not drag. You’re doing like this up and down cutting motion. See cutting is much kinder and nicer to the composite than dragging do not drag composite.

That’s the pearl right there. This is to be applied anteriorly posturally no dragging guys use some brushes if you need to avoid dragging anteriorly. And you’ll end up with a better result.

Hello, Protruserati. I’m Jaz Gulati. I’m forgetting to introduce myself nowadays. I know you guys are all family. Most of you are returning viewers, but if you’re new to the podcast, welcome. You picked a bloody good one to join us on. Before we join it, I just want to give an announcement about the offer that’s ending on 3rd of March. So, Protrusive Guidance is a free platform, right? If you want to come for the love of the community and a place to discuss your cases and just be a sponge and absorb and grow and learn together, then come and join us.

The website is protrusive. app. We do have a human process of approving each person. So if we have any doubt that you are not a dental professional, you ain’t coming in. So if you’re still waiting for an approval, chances are you haven’t checked an email that Mari has sent you to just validate, maybe asking for a certificate for those we found it difficult to verify.

Now, some of you will want to take advantage of the Ultimate Educational Plan. That plan is 39 a month or US$ 49 a month. There’s also a plan in Euros and Aussie Dollars for my Aussie fans out there. If you take advantage of the annual plan, you get 27 percent off. And that generous 27 percent off expires on 3rd of March.

So if you’re on the fence, you need to make up your mind by 3rd of March. If you want to go all in on Protrusive, all the education that we have to offer, do it before 3rd of March to get 27 percent off on the annual plan. And listen, if you get the plan and if all you do or if it’s just one thing that you do is that you watch Vertipreps for Plonkers, the five videos approximately just over an hour each, and you’ll be able to then prepare your first vertical crown for a pre molar using something called the shoulderless technique.

That’s the mission, then you will have got your money’s worth, like way, way more than your money’s worth. Just by doing that one mini course. We’ve also got Sectioning School launching. Just by the time when this one comes out. So by the time this come out, sectioning school, 4K, high quality videos of me sectioning teeth for extraction.

So this is probably be the best clinical footage of extractions you’ve ever seen. I’m no oral surgeon, but I’m a generous general, and you got my classic commentary as I go through each bit. So 3rd of March, the date. If you are interested in the ultimate educational plan, it’s a good time to upgrade to an annual plan.

Take advantage of that 27% off. Oh, and by the way, if you are in Ireland. If you’re one of my Irish Protruserati, I’m so sorry for some reason the bank’s having issues authenticating, so some of you having to pay by Apple and various other ways. I have no control of this. I’m so sorry. It’s been a surprise.

I’ve got dentists from Estonia, India, UAE all joining in the fun. But for some reason, if you’re in Ireland, the banks are not liking Protrusive at the moment. I don’t know what it is. Which is a real shame, because my top three Protruserati it’s like choosing your children, like who are my top three sets of fans?

I would say it’s the Irish, because over the years, the Irish have been the ones that have kept me going with their emails. Their generosity with their kind words and encouragement, I’ll never forget the Irish Protruserati for that. The second group that are going to get a shout out is the Ghanaians.

If you’re a Protruserati in Ghana, I love you. God bless you. You guys are always there on my live webinars and all the courses we do. So thank you so much. And the third group are from Birmingham in the UK. I don’t know what it is, but there’s a hotspot in Birmingham, which has the most protrusive per square meter of the world in that place.

So shout out to all the Brummies. Anyway, enough of my ramblings. Let’s join this epic episode with Dr. Ahmed Tadfi. You can thank me later. We’ll catch you in the mid roll and in the outro.

Main Episode:

Welcome to the Protrusive Dental Podcast. I’ve been admiring your work from afar, I guess, on social media and your journey and stuff. So it’s great to have you here as part of adhesive month. So February is adhesive month and we’re talking about bread and butter composites. And I’m really excited just to break down your protocols about how we can make our posterior composites faster, more predictable, efficient, hopefully sexier, all those things, basically, before we get to that.

Ahmed, tell us about you. Tell us about your career aspirations. How about your journey? I always want to spend a bit of time to unpack each individual’s journey.

[Ahmed]

Thank you very much, Jaz. I’m super excited to be on your podcast. I’ve been seeing a few of them in the past, but it feels quite surreal to be part of it. So actually I had a very long journey to dentistry. When I was 12 or 13, my dream was to be an architect, actually. I remember in year 10, we had an opportunity to do a work experience in the field of choice that we were aspiring to go into, and I remember feeling quite disappointed with that career choice because it wasn’t what I thought.

So I really like art. I really like sitting and precision and things like that. And I realized no offense to the architects at the time, but all we were doing was making cups of tea and doing nothing really. So I didn’t feel that it was applicable to me because I also wanted the science part of what we do.

So having that like patient communication or people communication as well as the artistic side of like making people’s smiles better and changing their life actually. So, I mean, although our medic counterparts have banter with us. We actually do change people’s lives in many ways just by doing simple things or more complex things.

So yeah, I then was walking by my own dentist and I just thought, I just saw a before and after picture and I thought, wow, this is really incredible, like the difference. So I remember walking upstairs and saying to the dentist, is it possible to do work experience again? I’ve just done work experience, but I wasn’t really satisfied, so I just feel like this is my career choice.

And he said, okay, let’s see how I can put you off this. And as they say, the rest is history. I started doing every Saturday is just going and watching and learning from different specialties. And I got really attached to it. And I kept saying to my friends, I want to be an endodontist. I want to be an endodontist.

I was like, oh, that’s a root canal specialist and I mean, weirdly, I still enjoy root canal treatment. Like it’s one of my favorite things to do, not a specialist at it, but I really still enjoy it and didn’t get my grades went to quite a rough school, so it wasn’t very easy to get grades, had a supply teacher.

Every other week we had fights in exams and people, Central London. Yeah. So it was, it was quite a rough place, but I guess it built my character a little bit and it made me really push through. So I had to do biomedical science and then again, I was really lucky because I’ve just about scraped a 2 1.

But fortunately I had a conditional offer from Birmingham. And yeah, then I started to realize the dream. And even to this moment, 10 years post grad almost, I still I can’t believe that I’m a dentist, which is quite weird.

[Jaz]

That’s beautiful. And then it’s a bit like when you pass your driving test a second time around, just remember and you appreciate and you appreciate the struggle. A lot of our colleagues, they kind of fell into it by accident. You had this determination and I hear this story on a podcast where I really wanted it, but I didn’t get first time and I had to go around. And then it’s a bit like when you pass your driving test a second time around, just tastes a bit sweeter and you really appreciate it a little bit more sometimes.

And I’ve heard this again, the same story again and again, and I think it’s so nice to reflect that and tap into that feeling, that desire you had at one stage. I mean, I want to be a dentist since I was 14 and I really remember just praying that I get the offers and I got the offers and praying.

I got the grades and routes being so desperate. I want you to do before going to the profession. And it’s so easy once you’re there to not appreciate it for all the doom and gloom. And so I love that you said that it’s really important reminder to main reminders from reflections on Ahmed’s message there, guys, is number one, that doesn’t matter what grade you get, that will not determine the quality of your work is success.

The grades does not equal success even at dental school and before whatever. So forget about grades. Okay. I think still to apply yourself, do your best, but just because you didn’t get the top mark doesn’t mean you can’t be a fantastic dentist and have a fulfilling career full of enjoyment. And the other one is just remember why you came into the profession and tap into that energy when you’re feeling a bit down.

[Ahmed]

Absolutely. I just add to that, actually you mentioned about dental school, even dental school. I wasn’t really a lectured person. I liked to listen to a lecture, but I wasn’t one of those people that would take notes down and go over things. I was more practical, hands on, wet fingered. So even in third year, I had to repeat third year, which for me worked out the best thing ever because it was the easiest year, ironically, for one subject.

But it was the one subject in biomaterials. But it made me do all the other subjects again, without having to do any exams for them. But in addition to that, I have an extra year of clinics. So at the end of fifth year, I managed to pick up like a couple of awards from dental school, which even I wouldn’t have imagined that I would be sort of in the position to.

So what I want to say about that is that the time I felt horrible, I felt sad. I felt like I let down my parents, my friends were moving up and I was like making new friends or had to be making new friends. So if anyone’s in that position, I really believe that God always works in ways that we don’t understand.

So everything that happens, yeah, it just happens for the best for you. Like, I always tell the story to Ibn Tanzim, even patients, about the king and his apprentice who would always go out and about and his apprentice, whatever happens, would say to him, oh, this is God knows best. God knows best. So one day the king cuts his arm and the apprentice says, Oh, don’t worry.

God knows best. And the king says, How dare you say that? I’ve just lost my arm. How can you say God knows best? Go to prison. And the next day, the king goes out without his apprentice, gets caught by a tribe, and the tribe take him to sort of give him to their gods or their spirits as a gift. And they realize his hands dropped off.

So they said, oh, we cannot give this to our gods with the hands chopped off, release him. So the king goes back. He pulls his apprentice from prison and tells him. Oh, look, this is what happened to me. You were right. God does know best but tell me one thing what happened to you you ended up in prison. So that was a bad thing for you surely he said well if I was with you they would have let you go, but they would have taken me because I had nothing. So God does know best. So just like a funny story, but it really does In the grand scheme of things, it doesn’t change a lot if you have to do another year. I know a lot of great clinicians that had to do another year. But just think of it in that way.

[Jaz]

I appreciate you sharing that parable. Very good. And just to, different learning styles, like you were not into lectures. I mean, I was massively into my lectures. I used to be there front row. Most of the time I was happy to be sitting by myself, front row, had my iPad out, I was recording the audios, I was typing notes, there’s a really cool app at the time called SoundNote, I was in love with it and stuff, so I was, I was always really, really into it in that way, but everyone’s got different learning styles and stuff, but regardless, if I hadn’t done as well academically, I don’t think that’s what determines your success in the future, that a theme that I’ve covered, to add on to a parable you mentioned so many times on podcast four is, the whole Steve Jobs quote.

You can’t connect the dots looking forward. You can only connect them looking back. And so that’s always a good thing to revisit. Now, the main topic for today, I mean, that was brilliant. The main topic for today is the espresso technique, which I really want to just see, we in there before we hit record, but you’re telling me about it and then how you used to be known as a fast modeling technique for composites.

And so I’m really excited because I don’t use this at the moment, but I know that I’m going to give it a go after our chat today. So my job is to make it tangible enough for myself. And then to also through that energy, make it tangible for the Protruserati, so that we can actually have all the benefits of it.

So I think the best way to approach this would be is why don’t we just look into how you were taught to place a posterior composite and maybe as a new grad, the techniques you were doing, like my anatomy in the past when you’re a new grad, it’s hit and miss, you spend a lot of time doing clues adjustment, you kind of lost, you don’t know the sequence and eventually you pick up, okay, let’s turn it into a class one first through the marginal ridge first and you figure that out, but then you’re always developing your style.

You go on courses, you experiment, you always think about how can I minimize that shrinkage stress? So I want to hear the warts and all story of your own progression, your own approach, your own recipe for your posterior composites and what happened, how that led to, and then we’ll break down the espresso technique. So please, Ahmed, over to you.

[Ahmed]

So again, very interesting one for the first three years post grad, I must admit they were probably the most difficult years of my career because I qualified thinking, wow, this is the dreams come true. And then going into practice thinking, Oh my God, what the hell have I done?

Like, from numbers of patients to not knowing everything, or not being able to find the right materials, the right instruments, not working with the same staff members, and I thought, gosh, this is really tough back to the clinical part of things the way I was placing composites was kind of similar to what we were taught at university.

So try to get some isolation, whether it’s rubber dam or not. Again, this was a struggle in the beginning because we didn’t really know what rubber dam was in the practice I did, but no one else did and it was like-

[Jaz]

As a new grad we’re using just interesting everyone’s different and you probably aren’t using I’m not using rubber dam and they fall into bad habits and they fall out of habit of using it. Even though they were taught in school as a new grad were you quite pro rubber dam from the start?

[Ahmed]

Yeah. So I had a really OCD picky thing about rubber dam and auditing all my endos. So for the first two years of my career, I remember walking around with like two USBs and putting every single endo x ray that I did. Good, bad, long, short, exposed, perforated, you name it, it was all on there.

And I said to myself, this would be my kind of self critique, because for me, you’re your worst critique, you’re your worst sort of analyst, if you like. And that was what I was using to improve. Now with regards to composites, I mean, I was very fortunate to be taught by the late Louis Mackenzie. Rest is in peace and his soul.

He was like instrumental to everything I do now. He was the guy that made me fall in love with the artistic part of dentistry and being interested in how to make them look beautiful, but functional and all of that, but once you qualify, you don’t have the time that you had at dental school to be able to afford to do that.

But there was me trying to push the boundaries and trying to do what I thought was the best thing to do for the patients and spend 1, 2, 2. 5, 3 hours on one tooth. And in the end, I would find that, once I took the rubber dam off, got the patient to buy, I’d spend another half an hour cutting it all back.

And again, on the course, I always share a story about seeing some of the archive pictures on my hard disk. And there was a tooth with like eight cusps on it. And I was thinking, what on earth was I like doing? So making things up, and I got to a point where at the third year post grad. I was feeling the financial pressures.

I was feeling drained. I was feeling mentally like challenged. It was all becoming too much because I was in debt. I was running late every single time for no reason. My work wasn’t good.

[Jaz]

Especially if it was maybe an endo or a composite because you’re trying to exert yourself and then you try to do all your wonderful anatomy level up portfolio building, that kind of stuff. And then it ends up being running late. It happens.

[Ahmed]

Exactly. And it was just catching up. And at the time I thought, you know what, I’m going to call it a day. There was one instrument that we used with Louis Mackenzie in fifth year, which was the StyleItaliano Fissura made by LM-Arte. And it was this like fluorescent green with a really nice pointy edge.

And I was fascinated by this instrument, believe it or not. And that was the sole reason why I googled StyleItaliano. And I thought, you know what? This looks like a nice course. It’s in a beautiful setting in Italy on the coast. Can’t go wrong. Let’s go for a holiday and then I’ll come back, hand in my notice and do cheffing or something like that. I was ready to quit dentistry actually.

[Jaz]

So this was like the last supper for you. This was like, okay, let me just go out with Bash. Let me just do a tax deductible course somewhere and then maybe I won’t have to look at teeth ever again.

[Ahmed]

Yeah, exactly that. Seriously, like it’s amazing how things work. I got there day one. I was like, you know what? It doesn’t really matter, but I just want to see how amazing, like why are these guys so amazing and stuff. And I sat through the talks and then I did the hands on and every day it was a four day course. And I was thinking, my God, like my work looks really good and it hasn’t taken as much time as I thought it would.

And they’re showing me 10 year, 20 year, 30 year follow ups like, okay, this is the recipe to success because it doesn’t have to be over complicated. It doesn’t have to have every single detail that God created because no matter what we do, we will never be God and actually it looks 99. 9 percent better than anything I’ve ever done.

Let’s give it a go. So I thought, you know what? I’ll give it a go. The first month I was practicing the techniques and I was thinking, my God, this is so crazy. I was becoming proficient, efficient, profitable, and I just thought this can’t be true. Because this isn’t what we were taught at university, but somehow it works.

And it was that phrase, there was a phrase they used in the lecture, which was simplicity is the ultimate sophistication, which is something that da Vinci quoted. And it blew my mind. It really is. Simplicity is the ultimate sophistication because instead of using everything that you know, and trying to put everything that you know, in one thing, and just taking everything that works from those steps and applying it, you’ve not only cut out the steps, but you’ve cut out the mistakes, you’ve cut out the voids, you’ve cut out the risk of making a mistake because the more steps you add, the higher the chances you make a mistake and the confusion with your team.

Because again, if you don’t have the same staff member, or they’re sick, or they’re away, or you work in a different site, you have to be able to relay that information very easily, very proficiently, without confusion to your partner, essentially in work. And it just made everything so much easier. And with that ease, all the other things fell into place.

Efficiency, proficiency, profitability, and they have this really nice motto, industry should be feasible, teachable, and repeatable, and then profitable, because you need to make a living, but those three things. Feasible, teachable, repeatable. And if you can get those three things with anything you do, you’ll be successful. With your patients, with your staff, with yourself.

[Jaz]

I see where they all come from. But the teachable one, I’ve been reflecting on this because you’re in education, I’m in education, right? We know, I’ve been reflecting a lot about this. And I think that maybe even that teachable one, we should change that word. I know where it comes from, I think we all know where it comes from and the reason behind it, but I think a better term might even be learnable.

[Ahmed]

Yes.

[Jaz]

You know, it’s teachable is more in the teacher perspective. I think learnables in the learners perspective.

[Ahmed]

Yeah. So again, if you look at the learning pyramid, you’ll see that 5 percent of knowledge is retained by reading or going to a lecture, but 90 percent of your knowledge is retained when you can teach that thing to somebody else.

That’s the golden nugget right there. Not the lecture, not the audios, not the rewriting of the lecture. But being able to relay that information to somebody else, that’s when you know you’ve got 90 percent of the information in your head.

[Jaz]

I am a big fan of encouraging young dentists to go on courses and then the next week, obviously getting to implement it, but just arrange a meeting with the other associates in practice. So whenever you book a big course, right, that you’ve been looking forward to, just tell your work colleagues, hey guys, I’m going on this course the week after on the Thursday when we usually have a dentist meeting. Can we just make it about everything I learned on this course? How wonderful would it be for that individual who went on that course to share everything to really harness the power of the learning, right?

And really cement in place and then to also spread some joy and knowledge and efficiency. So I think that’s going to be the Protrusive Dental Pearl for this episode. There we are to start sharing because that’s the highest form of learning. And just like you said, I think this is where the magic really happens.

So when you actually came away from Italy with that technique and you’ve been using in place and just tell us about the beauty of the term. So at that point, it was it fast modeling technique as we know it, or is it was it already called Espresso? Just tell us about the evolution of that before we then describe one example scenario.

[Ahmed]

Sure. It was actually in 2014. When professor Louis Hardan, a professor of St. Joseph’s university in Lebanon and Dr. Murad Akhundov from Azerbaijan, they actually came up with the technique, the fast modeling technique. And what they did is they published a paper in polymers. I don’t remember the impact factor, but it was quite a high impact factor for the study they did.

And they showed a one year follow up using a bulk fill material and the technique, which was fast modeling technique. And I think you can just type in a fast muddling technique, polymers.

[Jaz]

And we’ll put it in the show notes and the downloads.

[Ahmed]

Yeah.

[Jaz]

Protruserati just interfering here with an update about Nafisa. You know, Nafisa is a girl who’s the daughter of one of our own, one of our own Protruserati. Her name is Sakina and her daughter, Nafisa needs our help. She’s got SMA type one. Now I made a really important video talking all about this condition. And if you want to see that, it’s on our Instagram @protrusivedental.

But essentially we’re against the clock here. We don’t have much time. We need your donations to help save her life. Even if it’s just something like 100, that would honestly go so far to getting to that 1million dollar mark, that actually they can start the therapy and save her life. And then they have a whole 800, 000 still to pay from installments, which I’m hoping we can catch up to as well.

But they’re basically at 860, 000 at the time of recording this, which is spectacular, but we’re not there yet. We really want to save Nafisa’s life. So don’t hear it from me. I’m going to play this one minute video of Sakina’s plea.

Hello, Protruserati. My name is Dr. Sakina Isaji. I’m from Dar es Salaam, Tanzania. I’m so grateful for Dr. Jaz for giving me this platform. I never thought I could ever get here, at least not for this. Today I’m here to fight for my daughter’s life. My beautiful daughter who has a rare genetic disease called Spinal Muscular Atrophy type 1. We have been fundraising for her. We have raised 840, 000 so far, and we still need about 1 million to get her treated on time. I urge you all, if all dentists can come together to join this cause, we could save her on time. I believe every life is worth saving. Please help me save my daughter.

Protruserati, you’ve been following my newsletters, I’ve been emailing you as well, and every newsletter, I talk about Nafisa and how you can donate, so please go ahead to one of my old emails and then click the link to donate, or just head over to protrusive.co.uk/nafisa, N A F I S A, that’s her name.

Now when you get there, it’s like a Canadian fundraising page for Nafisa, which actually feeds into the main fundraising. So the amount you see might be over 200, 000 Canadian dollars, but don’t worry. This is still legit. This is still the same cause for Nafisa. I’m hoping that we can all club together and help one of our own. Thank you.

[Ahmed]

Anyways, it goes through that and it showed that actually it was not only more predictable to do, but the results versus the traditional layer by layer or increment by increment this, this was on that level, if not better. And why that’s important is, as we already mentioned, if you’re able to implement a material.

Or use a material in a bulk filled manner doing all the other things first, which we’ll talk about in a minute, but and be able to place a single shot of material in one go and then carve it out. Not only do you eliminate the risk of voids, air bubbles, all that stuff, but when you actually do. the cutting because you can essentially erase everything and start again.

You can actually get much better cusp formations and anatomy overall without making the mistake of building a cusp, maybe over building it or under building it and then having to go around that by building all the other cusps or go back and cut. It’s a really nice way. If you’ve got one single mass.

You can build everything up, check it before you cure, if you’ve got a mistake or something. Essentially, erase it or erase that part and redo it without the risk of having a problem later on. So now, more recently, just to unify the term-

[Jaz]

I was actually recording with the BioClear guys yesterday. And so very similar concept, so essentially over contouring and being reductive. Right? Is it a fair way to describe it?

[Ahmed]

I would say that not really overbuilding. No, it would be more following reading the tooth. So you would build a mass, let’s say four mils. It depends on how deep your cavity is. But even if you’re using a bulk fill, we do say use bulk fills cure up to six millimeters.

And they cure from the base to the top. That’s how the particles are made to work. We would never do 6 mil. We would do maximum 4. So depending on the depth of your cavity, if it’s, let’s say, 5, you do a 2 mil first, and your final 3 or a 3, and then your final 2. Nothing less than 1. 5, essentially. But let’s say you got a 4 mil cavity.

Once you’ve treated the cavity, and there are things that you have to do beforehand. But imagine when you put a single shot of composite in one go, you are eliminating the risks of voids, bubbles, things like that, because you’ve got less tampering with the composite. That’s the advantage of the technique. Then when you’re cutting the composite, you are reducing the shrinkage stress anyway, because you’re cutting each cusp. at a time.

[Jaz]

Oh, okay. This is where I got confused. This is the beauty of me. I’m glad I didn’t read up on it before I spoke to you because this is me now in the same mindset of someone listening to this for the first time, right? So when you said cutting, I thought you meant like once it’s cured, you get a bur and you cut back. That’s what I thought.

[Ahmed]

No, no, no.

[Jaz]

Actually. Yes. What you mean is using that Fissura instrument or similar and actually doing the magic bit, which I can now visualize, but you’re going to explain shortly. Okay, wonderful. I’m now in a happy place.

[Ahmed]

Okay, good.

[Jaz]

So let’s go with that. So that’s why I thought it was reductive. You see, okay, now it makes sense. I think the best way to approach now is let’s just talk through a scenario. The scenario is a lower right first molar. It’s a leaking distal occlusal amalgam restoration classic.

It is for the sake of covering all bases. It is going to be a five and a half millimeter depth cavity. Okay. And it is just very slightly subgingiva, a little bit tricky, but it isolates and everything. In fact, let’s not even talk about isolation. Let’s talk about, it’s there, you anesthetize and then go from there. Just, I want to know your exact step by step sequence, every geeky goodness, and I’ll probe you various stages.

[Ahmed]

So actually it starts with the radiograph first and foremost. So reading the radiograph before you start, that gives you all the clues or most of the clues as to how to approach the treatment. I like to use the power of three super gingival, sub gingival, crestal.

If it’s super gingival easy, you don’t need to consider gingivectomy crown lengthening or whatever. A wedge and a rubber dam does the trick. If it’s sub gingival, you might have to do gingivectomy. You might have to use a bigger wedge or you might have to do some form of non surgical crown lengthening.

And if it’s crestal, obviously you might have to pick up a blade or do crowning thing before do anything else. So we start with that first and then we move on. Now the scenario that you’ve mentioned is subgingival. Again, if it’s subgingival but not crestal, then usually I’ll just place the rubber dam. So once I’ve anesthetized, the rubber dam goes on.

I like to do a quadrant isolation, so whether I’m doing one tooth or three teeth, I’ll isolate from the distal most tooth to the central incisor. If they’ve got a retainer, then it’ll be distal most tooth to the four or five, and then the opposite five, again, just to retract the rubber down in a way that you can visualize the whole area.

[Jaz]

So it’s split down, so between the retainer part it’s split down?

[Ahmed]

Oh, no, you just do, let’s say, 7,4 – 7,6,5,4. And then 4. It pulls the gum down and just pulls them off.

[Jaz]

Hide over the incisors basically.

[Ahmed]

Exactly, exactly. And reduce the risk of saliva creeping in and stuff like that. And then the next question is to pre wedge or not to pre wedge? That is the question. So depending on where the cavity is, you would either pre wedge or not pre wedge. Now, when you wouldn’t pre wedge is if you’ve already got a broken contact and you’ve got, I don’t know, sharp area or cutting area, obviously you probably want to remove that before you even try the rubber dam even because you will tear the rubber dam as no matter how many rubber dams you go through.

So all of these things you have to think about before. The other trick I would say is take a piece of floss and if it goes through and it keeps breaking, Then you know that your rubber dam is going to probably tear and break. So you might be better off cutting the cavity before you put a rubber dam on and then putting on the rubber dam to do the next steps.

But let’s say that’s fine. Then pre wedge and choose the right wedge. Again, there’s a fantastic article on the style Italian website called mind the wedge. by Dr. Giuseppe Chiodera, and he basically goes through everything about wedging, like from wooden, plastic, silicone, cutting, wedges, customizing, the whole shebang. Free, so not to bore them about wedges.

[Jaz]

We will add that on because we all like a bit of info. I mean, nowadays I’m doing a lot of wedge lists because I’m using certain matrices that negate the need for that, which is great. But I mean, I’m still wedging the time, especially when I’m using my sectionals and the circus and the trial error and the trials and tribulations, but when you learn a bit more and get a lot of experience, which wedge to use in which scenario, how to modify the wedge and when to use a diamond wedge, all these little nuances that we love in restorative dentistry.

[Ahmed]

Exactly. And then I would cut my cavity. Now, this is a very important thing when it comes to restorative. One thing that we’re taught at university and I appreciate, and I think we should respect, but not to be too bogged down by is minimally invasive dentistry. Now the term minimally invasive dentistry doesn’t mean to be highly stupid dentistry.

So what I mean by that is that when we cut a cavity, we have to think about why are we actually cutting the cavity in the first place because. Primarily, the patient isn’t cleaning it. If the patient can’t clean it, what makes us think that if we remove just that part of the cavity and restore it again, that the patient’s going to be able to clean it?

So we’ve got to ensure that the cavity is cleansable by the patient first and foremost. And secondly, if it’s hard for the patient to clean, it’s going to be hard for us to restore. The smaller it is, the more difficult it is to place a matrix to place a wedge and more importantly to place material. So one thing that Walter Devoto told me again on the course was to be conservative is not to be stupid, probably print those phrases out and put them on every single dental school entrance, because that has changed my life really.

Why not use the word optimally invasive? Rather than minimally invasive. So to be optimally invasive means two things or three things. One, the patient can clean it, whether they brush twice a day, 10 times a day or no times a day. It’s more cleansable. Two, it means it’s easier for us to restore.

And if it’s easier for us to restore in a class two setting where the most important part of the whole restoration is that class two wall. If you’ve got a leak there, if you’ve got a problem that it doesn’t matter what you do. After that, it’s a failing restoration. So we are able to be more predictable to treat that part.

And therefore the success of our restorative treatment is higher. And that’s how you win your patients. That’s how you gain your colleagues trust. And that’s how you build your rapport and confidence as well, because the last thing you want to do is think in your head, oh, I’m a really invasive dentist, but the patients come back with a second round of carries in the same spot.

There’s a problem there. Then you’re going to cut even more of the tooth away. So you’ve got to be smart with your cavity design. So flare it, make sure. that it’s accessible by the patient with a toothbrush. More importantly, then you move on to the next bit, which is matrix.

[Jaz]

Before we cover matrix one, give a few reflections on total sense you’re talking when we’re being minimally invasive. Lincoln Harris taught me that minimally invasive is not a goal. It’s a modifying factor. The goal is like you said, to get a cleansable restoration and someone who may be more carries prone. And therefore you can’t be but the goal can’t be minimally invasive because if we do that, then it won’t become cleansable.

So we have to remember that that’s a modifying factor. It’s not a goal. Sometimes we have to remember that the matrices that we’re working with, and you’re going to cover this, obviously we have to design our cavities to accommodate our matrix because If you don’t design a cavity well, and then you get a kink in the matrix, then you’re not using the matrix how it was designed to be used.

We sometimes need to be a little bit slightly more invasive to allow the passivity or the correct functioning of the matrix the way it was designed. And so that’s really important. And then the last thing there is the struggles of a claustrophobic class two, right? We hate doing these claustrophobic class dues.

And so having more space is just going to reduce your stress massively and actually makes you eat a better outcome. So totally echo everything you said there. So please tell us about matrixing, but I’m really excited to get to the actual bit where the espresso technique actually comes in place. But by the way, what you’re saying, please continue. Cause I think we’re getting so much value from, cause you’re not only just giving us a protocol. You’re giving us the why and the reason. So I’m really enjoying this so far. Please keep going.

[Ahmed]

Thank you. So now it comes to the matrix thing part, which again, a lot of people have quite a lot of stress about or confusion. Unfortunately, to this day, there isn’t one matrix system fits all. So you might have to have two different matrix systems in your practice to kind of cover everything. There are some, maybe a ring coming out, which might cater for everything, but for now, I’m not allowed to talk about it, but if you had to choose two, I would say the Polydentia system and the Palodent system.

Works very well or Polidentia and Garrison Composi-Tight, or I’ve never used the BioClear system myself personally, but I’m sure use the system that you’re familiar with and that you’re comfortable with is what I would say. And if you’re not sure, if you don’t know, then obviously go on a course and try it out or see your colleague and see how they do things and go from there-

[Jaz]

But let’s just say having six different matrix systems, as a business, so it may be that if you want to do bioclear, go on the bioclear course and embrace their philosophy and then 10, 20 percent time, you just have to have the other backup matrix for the other scenarios where it may not cater for it.

Or if you’re going to go all into polydentia and then have the other, I agree, not one matrix, but two, three systems max that you have in the practice and that is going to be enough. But I totally agree. There’s no one matrix that’s going to be optimal.

[Ahmed]

Yeah, exactly. Now, the question about pre wedging or not pre wedging, the advantages, let’s say, of pre wedging are the most obvious, which is separation of the teeth. Again, when you’re using rubber dam, you will get some separation of the teeth from the rubber dam itself. But obviously the more separation you do or the earlier the separation you do, the higher the chance you have of actually moving those two teeth away from each other and reducing the risk of iatrogenic damage.

The second important thing with pre wedging is again in a deep cavity, the longer the wedge is in that sulcus for the higher the chance or the more that the gingiva is depressed by the wedge, which means that if you’ve depressed the gingiva over that time, you’re going to access that cavity much more predictably than you would if you then saw, oops, I’ve got a slightly deeper cavity now, now let me put the wedge in.

The risk of then putting the wedge in, not pre wedging, is that you might tear your dam. You might have some bleeding if you’ve been cutting the bow and you’ve accidentally slipped and you’ve shredded the rubber dam itself. There’s so many little things that can happen along the way. So again, if you’re not sure, my advice would be pre cut your class two before you put the dam on and then wedge and dam and wedge and go ahead.

If you’re definitely sure based on your x ray. That you’re clear of the gingival margins, then pre wedge is what I would do. And then I would check my cavity, make sure that I have no undermined enamel. This is another thing, a bit controversial. Again, if we think about it logically, a lot of the time when we are doing the class two cavity preparation, we end up with a very thin amount of enamel.

And what I used to do even before I was taught this way is I would take an ultrasonic and whiz it all away. Or I would take a thing, a chisel and chisel it all away. And if you think about it, you’ve just removed the best bonding material that you’ve got in that space. So unless it’s like completely thin and you can see it’s all cracked and broken apart. Try to preserve that extremely precious bit of enamel there and what you can do before you remove your wedge or if you’ve not wedged, it’s more even it’s better if you haven’t wedge is reinforcing just that part with a drop of flowable and making it strong enough to put a wedge in and then do your matrixing and your class two.

So there’s a little bit of. talking about that. I don’t want to confuse the audience, but this is maybe for a course, but let’s just ignore it. And let’s say we’ve got perfect enamel and everything’s is lovely. You put your wedge in or you take your wedge out. Sorry. Check your cavities clean before you put your matrix.

You want to clean the cavity or a final clean with the AquaCare if you’ve got it, or even a sandblaster. If you’re using a sandblaster, just be careful. You’re not too zealous with the button because then the patient turns into snowman. And a trick is just, if you get a piece of gauze and you wet the gauze and you place it over, then it will kind of soak up.

A lot of that sound if you don’t have an accurate care, but if you have an accurate care, just run it around your cavity. I also like to use a greenie just on the periphery of the cavity preparation. Again, almost like beveling the enamel because that will give you a much better integration of composite.

And also it will strengthen the composite in that area. Often when you see the shrinkage stress or you see composites after eight, seven years, whatever, you’ll see that white. Sort of a dark ring around and that’s because there’s not enough of a bevel, let’s say in that area, so it’s a little bevel around and then you’re ready for bonding.

Now, depending on the cavity spaced into proximal space, I’ll either put my sectional matrix in the right direction, or if I want to bond and I haven’t got a lot of space, I’ll turn it the other way around so that I don’t have bond on my matrix, because again, what happens is you end up with a pool of bond and once you cure it, you’ve got now half a mil of bond.

Or if you’re using optimal on the fell, you’ve got a millimeter or bond, and then you’ve got your composite. And if you take a post op x ray or you take an x ray in a couple of years or whatever. You think it’s a void or someone else thinks it’s a void, so yeah, it’s better.

[Jaz]

It’s like an open margin, almost.

[Ahmed]

Exactly. So you’ve got to be just be careful. Those little things again, depending on the bond system that you use. Now, if you ask me-

[Jaz]

How I get that, I didn’t quite get that bit, though. So what’s the tip in terms of reversing the matrix? So?

[Ahmed]

Yeah.

[Jaz]

So basically, you instead of using it as you normally do, you just for a moment, turn it around. And how does that actually prevent the pooling of the bond in that area? Yes.

[Ahmed]

So it doesn’t prevent pooling of the bond, but it prevents the bond sticking onto the bit of the matrix that you’re then going to use to pack your composite against.

[Jaz]

Got it.

[Ahmed]

So for that part, and then again regarding the pooling, what you want to do is you want to leave the bond for a minute or so just to naturally be absorbed by the tooth. And then if you’ve got a good 3 in 1, go around it gently. Check it on your neck or your arm first to make sure there’s no water or use the suction tip on sort of a halfway suction just to remove any solvent. Now, we missed a bit about etching, which I’ll just quickly go for, go through. I do selective enamel etch only.

And that’s because I’m using a universal bonding system. So going back to the easing and the predictability, let me just tell you one thing, guys, these companies, it’s in their best interest to give us the best material, because if it doesn’t work, we won’t buy it. And if we don’t buy it, they don’t make any money and they don’t make any more product.

I’ve been to the labs. I’ve been to the companies where they make these things. And if you think we’re OCD about doing fissures and dentistry, trust me when I tell you, the biomaterial scientists are the worst OCD people you can come across. They care a lot about what they produce. So, just to give you an example, Universal Bond, they attached a car and they lifted a car with Universal Bond.

So, If you use the bond according to the manufacturer’s instructions, which is very important, then the bond will give you exactly what the manufacturer promised, which is a good bonding, a strong bond, and you have no problems. You have you can sleep at night. This was another factor actually that changed my life because prior to that I was etching dentine.

Now unless you’ve got a stop clock and you’ve got the most incredible reflexes and your nurse is on the ball every time, you cannot tell me that you’re etching dentine for 20 seconds or 15 seconds or 10 seconds. There is no way. Never, no matter how good you are.

[Jaz]

So what happens is you’ve taken a photo of your etching the dentine, you over etched.

[Ahmed]

Exactly, exactly. So like one of the main things that we have is people say, oh, post op sensitivity, mainly because that dentine is being over etched. And when you over etch dentine, it means that you have a higher chance of over drying it. And then there’s an argument of people saying, Oh, but you can then re wet it.

Okay. I tried to re wet it, but at the same time, I’ve now wet my enamel. Okay, I’ll re dry it and then I’m over dried my dentine now, so you’re going backwards and forwards and okay, let me use the primer let me use this bottle and then the nurse gives you the wrong bottle because you’ve got three bottles out already and you’ve got a gloomer here.

You’ve got a primer there. You’ve got an a and b1 one’s blue one’s white. But there’s another blue one from a different thing. It’s so confusing. So having a simplified workflow makes it much easier to do your work. Now I’m not saying if you’re using a two step system or whatever, use it. And if you’re happy with it.

I have no issues at all. They all work brilliantly if you use them to their instructions, but just talk about me. So I selectively etch the enamel and another little tip when you etch enamel, what often happens is people etch the bit that isn’t really necessary. So they etch the top of the enamel and they forget about the inner part of the enamel, which is where you want your enamel to be etched, really, because that’s where you want your bond.

[Jaz]

So let’s say, that’s where the issue could happen more by the fissures they’re etching, but that enamel there might be one and a half, two millimeters thick. And then the bit where by the ADJ, they’ve missed that enamel there, right?

[Ahmed]

Exactly. And that’s a crucial enamel because that’s where you want your bonding to be very good. So one of the other things that we find with etching is that you press and it goes all over the place. So another tip, just like you do with your air, just extrude your etchant first on a bracket table or on a piece of tissue or something, make sure you’ve got a nice, smooth, consistent flow, or what I tend to do now is I extrude it onto a little pad and I’ll use the fissura and to run it across my enamel because I don’t want to risk an accident and whatever.

So I have a lot more control. So enamel. etch only for 30 seconds, wash it for 30 to 60 seconds. Now, this is also very important. When you’re not timing 30 seconds, it seems like two seconds. So if you think about 30 seconds, You might just do five if you time 30 seconds. It’s a long time. It’s a very long time so time 30 seconds at least and why I say that is because one of the byproducts of etching is Salts and now if you don’t wash those salts properly, you’ve got salts that are then Playing around with your bonding.

So what we’re talking about is important if you wanna get optimal bonding, and that’s what we all wanna do. So again, based on manufacturers, we need to make sure we follow their instructions in order to get the best out of the products that we’re using. But sometimes on a course, I say to people, what bond are you using? And they’ll be like, the black bottle. Which one is it? What do you use? I don’t know.

[Jaz]

When we ask them what medicines they’re having, they’re saying, Oh yeah, that purple pill, or the blue pill, or whatever. You know, like, how does that help you?

[Ahmed]

This is really important, Jaz, because, like, guys, if you’re using something, especially on a patient, and you don’t know what it is you’re using. So how do you know how you’re using it or how you’re supposed to use it? And then how do you know what you’re doing is actually going to be proper and right. So it’s our duty to understand or at least know what we are giving the patients, like you said, it would be like prescribing amoxicillin to someone who’s allergic to penicillin.

It doesn’t make sense. So you’ve got to know what you’re using before you actually do it on a patient, not just, oh, it’s the black bottle that was in the drawer or that the nurse gave to me, that’s where all the voids and mistakes and problems arise from us not knowing. What we’re using and how we should use it. So this is really important.

I wonder, I mean, if you’ve ever done this experiment on one of your courses, whereby you will ask your cohort how many of you etched dentine? And then you see the number of hands go up, right? And if you haven’t done this before, do it and do it next one, right? And then you ask them all which bond they’re using.

[Jaz]

And for those that know, and then you know, actually part of the protocol at a bond is that you shouldn’t be etching the dentine. It’s like someone messaged me once saying, Oh, my paracore kept falling away. Well, I did you and you know what? Tell me a protocol. And then I looked that bit where they said, Yes, I accidentally knows that.

Well, did you know that for the paracord protocol you don’t etch dentine? And so people that when they migrate from the earlier bonds to the more universal ones because they’ve always etch dentine from dental school. They continue to etch dentine and therefore that’s completely diminishing the bond strength of dentine by etching it.

So if anyone’s multitasking, they missed, they missed that. This is probably extremely important game changing, simple thing that you probably are sure you might be embarrassed, but there will be some dentists out there thinking, holy moly, I can’t believe I’ve been etching dentine when I shouldn’t have been etching dentine. And so it’s really important just to emphasize that.

[Ahmed]

As you say, on the courses, we do say that it’s amazing, but yeah, like jokes aside, this is really important. Now we come to the bonding. So as we said, I use a universal bond, important to try and avoid over pooling, especially in the class two area.

A couple of things