Managing black triangles with composite resin – often these are periodontal patients. Doesn’t that mean you’ll be bonding to root dentine?!

Continuing our Adhesive Month series in to March (oops!), we’re excited to bring you Part Two of our journey into the Bioclear Adhesive Philosophy. Building on the rich discussion from Part One (PDP 178), we’re joined once again by Dr. David Carroll and Diana McKenna as we shift our attention to anterior restorations. We focus specifically on the intricacies and challenges of closing black triangles.

https://youtu.be/AFlhZXTm32w
Watch PDP179 on Youtube

Protrusive Dental Pearl: Protect the unrestored teeth and restorations from air particle abrasion! Using a soft steel matrix strip, similar but softer than a matrix band, protects the adjacent tooth’s enamel when air abrading the tooth.

Example one I found on the market: Polydentia soft matrix strip (no financial interest)

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

Highlights of this episode:

• 1:33 Dental Pearl – Protect from Air Abrasion
  
• 04:19 Ceramic vs Composite Debate
  
• 11:17 Informed Decision Between Ceramic and Resin
  
• 19:22 Bonding to Root Dentine
  
• 22:33 Anterior Restoration Protocol – Heated Composite
  
• 29:57 BT Matrix System of Choice
  
• 34:35 Guidelines for Anterior Bioclear Composites
  
• 39:55 The Importance of Proper Set-up
  
• 41:46 Learn more from David and Diana
  

Take advantage of our upcoming Documentation Month this March!

If you want CPD or CE credits from this episode, just take the quiz. For premium app users, scroll down to download the notes. You’ll also get access to our special content like ‘Verti Preps for Plonkers’, Sectioning School, over 30 rubber dam videos, webinar replays, and clinical videos on various dental procedures. All these are available with our Ultimate Education Plan.

If you liked this episode, you will also like PDP178 – The Bioclear Philosophy of Adhesive Dentistry – Part 1 (Posterior)

Click below for full episode transcript:
Jaz's Introduction: Hello Protruserati, I'm Jaz Gulati and welcome to PDP 179. Now I know we are well into March at the time of publishing and we're still stuck on adhesive month, which was February. March is supposed to be documentation month, but don't worry. I've got some cool stuff coming to catch up in March, including what software I'm using at the moment to write my notes for me.

Jaz’s Introduction:
I know it sounds crazy. I have two, I have two dreams in my life. One is to never have to wash dishes ever again. And no, I don’t have a dishwasher. My kitchen is not big enough at the moment. And number two is to never have to write my notes again. So, you know, dishwasher can wait, but number two is actually almost happening.

And I’ve been on this crazy journey to discover the best software or the best way. So as part of documentation month, I’ll make it up to you by the end of this month to reveal which softwares I’ve tried and tested and which one I’ve decided was the best. This episode, of course, is the part two following the discussion that we had on the Bioclare Adhesive Philosophy.

Like, I don’t want this two part episode to be about the Matrix. Like, the Matrix is awesome. Like, we know that Bioclare matrices, they do very well, but I’m not here to shine a light on, on just the Matrix. I’m here to shine light on a philosophy like sometimes when we’re closing black triangles the nature of the beast is that we’re now bonding composite to root dentine that’s the kind of stuff i want to uncover that’s the geeky kind of stuff i want to discuss with dr david carroll and diana mckenna who did such a great job in the part one if you haven’t listened to it already PDP 178 discussing the posterior Bioclear protocol on this one we’re shifting our focus to Anteriors, think black triangle closures for example. We’ll discuss the nuances of the Bioclear technique and understand a few more nuances about black triangle closures.

Dental Pearl:
Now, every PDP episode, I give you a Protrusive Dental Pearl, and I’ll be honest with you guys, I’m not the best in remembering exactly which pearls I’ve given. Now, like now we are on PDP 179 hereafter, which means I’ve given you 178 Pearls already.

And you know what? Maybe I might have repeated myself once or twice. So let’s go with this one. It’s relevant to adhesive dentistry, and even if it is a repeat, I think it’s well worth it. Right. So air abrasion, you know I’m a fan of air abrasion and I’ve got a really cool episode all about air particle abrasion coming up with someone who’s on a PhD on this topic, basically.

So those of us who crave the geeky details about air particle abrasion. Should you use 27 microns or 50 microns? Blah, blah, blah. We’re going to cover that soon. Now, as we covered already in the previous episode, one of the reasons we use air particle abrasion is to really remove the biofilm, really effectively remove biofilm so that you can get bonding to the actual substrate that you want to bond to.

If you are bonding to biofilm, if you’re bonding to plaque, you’re going to get stain and you’re going to get early bond failure. Now imagine you’re doing a class 3 restoration, let’s say it’s a upper lateral incisor and you want to air abrade that mesial cavity. The issue is with most air abrasion units, you’re going to get it everywhere and you might even abrade the central incisor distal by accident.

The problem with air abrading that surface is that you make it rough and then you make it prone to staining. And that’s not cool. So what can we do at the time of air abrasion to prevent this? Well, I like to use this soft, really dead soft metal band. It’s kind of like a matrix band, but it’s like way softer.

It’s called Conform. And honestly, I don’t even know where to buy it from. By the time this gets published, I’ll put some links out there in terms of where you could buy this from or alternative materials that you could buy. But you don’t want to use a matrix band because matrix bands can be expensive and you want to use it for this purpose.

And also matrix bands can be, it can be thick and rigid, whereas you want something really soft, but you still want it to be metal. You don’t want to use PTFE. because when you air abrade PTFE, it perforates. So, by using this dead, soft metal band called Conform, I am able to now shield that central incisor against the effects of the air abrasion, and therefore, I air abrade the area that I want to air abrade, i. e. the lateral incisor mesial cavity, and I don’t damage the enamel surface of that central in this example.

And then we don’t get the disadvantage of the staining. Yes. I know it’s one more thing in your protocol, but I feel good about it. I feel good when I protect your adjacent teeth. Like I remember just being a little bit gung ho with it and seeing staining sometime later and thinking, hmm, I could have done something to prevent this.

And so I feel better when I’m using some sort of a metal barrier to protect the areas I don’t want to air abrade. Hope you enjoyed that Pearl. If you’re listening on Spotify or Apple, please don’t forget to rate the podcast. It means a lot to me. And if you’re watching on YouTube, hit that like button, hit subscribe.

This is how Protrusive grows and I’m able to make these cool episodes. So thanks so much. And let’s join the main episode.

Main Episode:
So it was very refreshing to see that. And I hope I have not offended everyone. It’s just a perception that we have across the pond that if you’re going to need a filling, we don’t believe in filling, let’s just crown it. Okay. That’s the kind of an in joke that we have in the world about the Americans, but I know that’s all changing.

Listen, I know that’s all changing. And so I hope that offended no one. I come from a place of respect. So tell me about your shift as a prosthodontist. And, you know, the whole term prosthodontist, impressions, making impressions, the lab work, seating with ears and stuff. What did it feel like to you shifting a lot of your work to, towards composite and away from ceramic?

[David]
Yeah. You know, Jaz, when I first started becoming involved with BioClear, they nicknamed me because I’m a prosthodontist. They nicknamed me the enamel assassin. Okay. And that was my nickname. And let me tell you, if you’re going to hang out with David Clark, you have to have a very thick skin.

[Jaz]
Because he’s a mad scientist kind of guy. I just love it. I’ve seen him. He’s just a funny, mad scientist, quirky, just legend.

[David]
Oh, he is. He is. So I’ve been called a lot of things. And so at our last summit, I retained the title of enamel assassin and Marco became the cost killer. So he, cause Marco gave a presentation and he said, I’m going, I’m the cost killer.

I’m the killer of the cost. So because he was basically showing his presentation where he’s overlaying everything to, to get everything into compression, you know, so yeah, so it was, it’s a, it’s a big shift, you know, getting away from prepping and stuff like that, but, you know BioClear is very patient driven, so patients get very educated today.

So we have patients that drive from hours and hours. We just finished a full mouth rehab, all direct, and I’ll tell you, Jaz, the American College of Prosthodontists, they would take me out back and they would find a tall tree and a short piece of rope, and they would haul me from that tree, just to tell you what we were doing on this lady, I mean, open vertical dimension, I opened her twice, okay, opened her three millimeters on a lower arch and another three on an upper arch, And entire full mouth, no articulator, no diagnostic wax up.

It’s insane. It’s insane, okay? And I hope that I don’t do too many cases like that because it goes against everything in my prosthodontic background. However, you know, this lady was, that’s it. She was determined that she was going to find somebody who was going to rehab her mouth without cutting down her teeth further.

And without prepping her teeth and, you know, so, the reality is we have to look at emphasis on different teeth. Okay, so if you have a large molar, that’s a heavy tooth, a big heavy molar. If you want to do a crown on that tooth because it’s got an MOD and a buccal cusp cracks off, I don’t have any problem with that at all. Now, I know David Clark may not like that recording, but I’m telling you from, this is from me, right?

[Jaz]
It’s just your reputation of enamel assassin just gets maintained. The next conference is fine.

[David]
Exactly. I’ve got to maintain that, right? I have no problem going full coverage on that tooth because first of all, it’s a big heavy tooth. You can still way away from the pulp. Alright, you’ve got plenty of tooth to work with, and if you put a good crown on that tooth, it’s going to last many, many, many, many years, okay? On a second molar, we still try to do gold crowns, because if the patient will accept a full gold crown on a second molar, I will go for that every single time, because that is the, one of the finest restorations in dentistry and I’m looking at my dad’s gold crowns that are 40 years old, okay?

50 years old, okay? You’re not going to see too many things in dentistry that are going to go that long, alright? So that’s the, that’s the pinnacle restoration. But when you get to anterior teeth, let’s look at maxillary first bicuspid with that furcation and the mesial and all that stuff like that. You cut that tooth for a full crown, a traditional crown, on somebody that’s had a little bit of bone loss, some recession in the root exposure.

And before you know it, you have this little figure eight thing that looks sort of like a tiny little, you know, and the lower anteriors are worse or they’re worse. They’re the worst. So when you get to the lower anterior part of the mouth, I honestly feel like at this point, if you have a lower anterior case, black triangles on a patient with lower anteriors, honestly, I think the BioClear method at this point is basically becoming like standard of care.

Because to take a burr and just start cutting those teeth for ceramics. I won’t do it. I will present the options. We have a video we present to patients, but I won’t do it. My dad taught me a long time ago, do not let your patients dictate your treatment plans. Okay? That’s words of wisdom from a guy who’s been down the road and been down the bumpy road many, many times.

And so, we inform the patient, it’s today’s a different world. My dad used to go in there and just start prepping teeth. You know, there was no discussion about A, B, C. He just go treatment plan number one. Your whole, you know, your full mouth reconstruction is going to be 30, 000. Go pay at the front. Boom, boom, boom.

Start cutting, cutting, cutting, cutting, cutting, cutting. Today’s a different world. It’s a different world. I think you could get in trouble for practicing like that today. I really do. Because I think if that patient leaves your office and goes and finds out that, Hey, I didn’t have to cut these teeth for crowns.

There was another method and this doctor did not inform me of that method. I think you’re opening yourself up So I think for that reason alone if people want to learn BioClear only to do black triangle closure. I have no problem with that at all. Go to learn just that just learn how to take care of lower anterior teeth without cutting them all down. You’ll be so happy you did you’re going to have patients driving from all over to see you, to find you and find you because we know we love doing adult ortho.

I know you love doing ortho I love doing some ortho too. I’m a little lazier than you so I probably do a little less ortho But, but, you know, when we do the adult ortho, I would hear I was fixing all these black triangles for patients. And, you know, I did an ortho case and I forgot to tell my patient that they could end up with black triangles. You know how stupid I felt, Jaz?

[Jaz]
Happens to us all.

[David]
Right? I thought to myself, Oh my God, what in the world? I mean, I have people driving hours to come see me and for some reason I thought I could do ortho without making black triangles. I mean, what is, you know, and I had to explain to the patient. After the fact, you know, I’m sorry, we’re going to have to do another procedure.

And guess what Jaz, I had to do most of that for free because I couldn’t bring myself to tell them, you know, so I had, that was a giveaway black triangle closure.

[Jaz]
When I first got exposed to the BioClear anterior technique, it was for the magic of black triangles. I think that’s really when the initial. Videos I’ve seen and David Clark talking about it, you know, it was like, this is, this should be the standard of care, but I’ve seen that evolve so much now, obviously with posteriors, which we’ve discussed in depth now, but when it comes to resin veneers, or just generally that decision making process that you have, what percentage of the time are you opting for ceramic and what percentage of the time are you opting for resin?

Now obviously the matrix of choice is the Bioclear for you. What are the distinctive features that you’re sort of looking at to sort of sway yourself to one direction or to another basically? Essentially, what are the, also the shortcomings perhaps? At which point you think actually this is a tipping point that perhaps we should still go to ceramic and maybe is beyond something like BioClear or just resin in general.

[David]
Yeah. So we were talking about before, before this program started, I was asking Diana, what does she think is the biggest advantage of BioClear over ceramics? And then what is the biggest advantage that ceramics has over BioClear? Because remember we stay neutral.

We stay neutral and we are trying to educate the patient to make the best decision for themselves. We will guide them on the decision, but in a lot of cases you can go either way. A lot of cases can go either way. So we try to educate the patient. So Diana, what do you think is from your perspective as a hygienist and a dentist, what do you think is the biggest advantage that BioClear has overdoing porcelain.

[Diana]
I think the biggest or what I noticed is why patients come to us. When they come to us, they said, I don’t want my teeth prepped. I don’t want that my teeth being cut for the material. So I think the biggest advantage of BioClear, what I noticed is that, that we don’t have to prep their tooth. We do certain preparations, but never like a crown or So, I, in my opinion, is that and porcelain color stability, even though BioClear has great cosmetics, I think the color stability in porcelain is a bigger advantage than that.

And as a hygienist, something that I see, I love BioClear margins. The gingival margins when I clean that, because we like to feel the smooth, we like to feel that smooth when we clean. And with BioClear you cannot feel the margin. So it’s something that-

[Jaz]
It’s a very smooth emergence. So you, it’s undiscernible with the probe. I mean, I, I know what you mean, or-

[Diana]  
Right, like when you clean, you cannot feel that, like the margin, the difference between the tooth. And the restoration.

[Jaz]
Infinity blend. I don’t know if that’s an official term you guys use, but it’s a, it’s a, it’s a good way to describe it.

[Diana]  
Infinity margin, right?

[David]
Yeah. The infinity margin. Yeah. It’s, yeah. When you get it right and you do it right and you nail the result, we don’t even know where it’s at. So that part, that’s a big advantage of, of BioClear is that infinity margin. And another thing we would distinguish between color stability at, on a patient who has stable gingival levels and patients who have unstable gingival levels.

So in other words, let’s say you have a patient that’s prone to recession and you see all their teeth, they have recession, recession, recession. I would prefer BioClear on that patient because that tissue is going to keep moving. More the likely. All right, and then so the color, the porcelain itself has wonderful color stability in the veneer itself.

However, that margin is going to become more and more exposed over time. And that margin there does not have very good color stability. It tends to pick up stain. And you see patients coming in with 20 year old veneers, you can see every margin, you know, every single one. And it’s hard to refinish that margin.

It’s a little, you know, you can try to do certain things, but that glass is unforgiving to try to get in there and try to polish that and try to make it blend. Where with BioClear, you can really go back and re, we had one of our cases was our oldest black triangle case is about eight years old now.

And she was just in a week or two ago. And I felt around and I felt like in the mid facial areas a little bit of overhang and I was able to go in there and just spend like, you know, 20 minutes and I just kind of refine, refine, refine, refine. And now I like it much better. Okay. Now, and her case is already like eight years old.

So she’s going to go and trust me, Jaz, I was awful when I did that case. I was so bad. Okay. I was sweating and sweating. You want to see a process on a sweat, right? So, you know, what’s funny is here I am trained my whole career cutting full arches, right? I’m in there cutting, cutting, cutting, cutting, right?

And I’m humming along buzzing enamel off, right? But for some reason that first black triangle case where I cut nothing, I was sweating. I was sweating. I mean I was just dying, right? I’m dying in there and the matrices were not as good as they are now, so the matrices were kind of floating a little, you know, and I’m kind of pushing them back down.

And by the way, Jaz, I had no experience with rubber dams, but Diana has been the goddess of the rubber dam because prosthodontists are allergic to all latex, including rubber dams. Okay. So, you know, so she was like, I was just telling her, go in there and do the rubber dam, call me when you’re done. Right.

So, you know, and just the little intricacies of all that stuff. So there was, so it’s a testament to the method, the fact that my first case, which I wasn’t good at, it’s still there. You know, does it look perfect on the x ray? No, it’s not perfect. But here’s another thing that’s interesting, Jaz. You do crowns, right, on teeth, especially small teeth, since we’re talking about anterior teeth.

You do crowns, let’s say you crown a maxillary lateral incisor. And you cut away 60%, 70 percent of the volume of that tooth in order to do a traditional crown, right? Now you take an x ray and it’s got an open margin. You know, you see a little opening, a little gap there, you know? You have to cut that crown off.

There is no options because the bacteria has a direct pathway into the dentin that the patient cannot do anything about that. Okay. Now on BioClear, the composite, I don’t want to tell anybody that they can be sloppy because we’re not sloppy. You have a chance to come back and correct it. You can correct it.

You can fix it. Okay. And the body, you have not cut the tooth. So even though you might have a little ledge or a little overhang or something like that, the bacteria does not have a direct path to the pole. Okay. And you have time, you have time, you could, a patient can go home and they can come back two weeks later and you say, you know, I’m going to just rework this a little bit. You can’t do that with Crown and Bridge.

[Jaz]
It’s a bit more forgiving with composite in general and that’s why it’s a beautiful material. A really great saying, Dr. James Baker in the UK, he said composite is a bit like being married to a supermodel. You sometimes forget how good looking they can be. I just love that saying, I heard him say it once and I thought, this is amazing.

And so you’ve got these other advantages as well, obviously with compositing, like, like you mentioned, so, so it seems really great that we have such a great versatile material. It’s like, you know, it’s changed the game in density in the last 20 years, how much we’re doing in resin. Just describe any, obviously, in the, in the, this will be a two part episode, as in the previous one, you talked about posterior protocol, anteriors where we have more enamel, we mentioned that you will be using the technique whereby once you’ve done the cleaning, which is still important, you know, the, the bioblasting, getting a nice clean surface, the matrix selection, which I’m going to ask you some tips for, once you’ve got that all secured, and you’re doing the bond, and you’re rubbing it in, massaging it in, but you’re not curing, because it’s the whole injection molding protocol.

You’re going to go with the flowable, you’re going to go with the heated paste, and I’ll ask you shortly which is what, why that’s different, which type of paste you would prefer anteriorly, I’ll ask you that shortly. But once you do all that, I’m just thinking about that scenario you mentioned about the recession, right?

Are we concerned about bonding to the root dentine? And, and, and, and therefore, are you then treating that differently, basically? So this is a higher level question, it’s a geekier question, I guess. But, but how can we get a higher level of stability in those less forgiving areas? Which I, I, I totally agree that if you put a veneer margin there, then you’re equally as screwed, because there’s no enamel.

If you’re doing a veneer, you want, you know, you can get screwed there. But I guess just some top tips that I’m seeking. So I don’t know how you want to approach that crappy question. I didn’t apologize. Not my best question I’ve asked, but in terms of just the differences between posterior and anterior workflow, did I get it all right when I mentioned that? And then how do you feel about finishing on the root dentine, I guess?

[David]
Yeah. So that is a great question. And so I’ll usually discuss with the patient. I inform them. I tell them, you know, the bonding is not as good down on the root. And because you have black triangles because you lost bone around those teeth and then the gum tissue went down and followed the bone.

So now you have these, these open spaces that you don’t like the way they look. We get very predictable bond to all the enamel. However, we know that the bonding that goes to the cementum or dentine, we know that that is going to be compromised long term. You know, we know that we can get great in vitro results bonding to dentine in a lab.

But in, in the world, what we see, we see something else. We see that those interfaces don’t hold up as well, right? Now, the good thing that we have with the BioClear is that we are shrink wrapping on lower anteriors. We’re shrink wrapping the whole tooth. So, lower anteriors, because they’re such small teeth, We’re not doing one eighties, almost never, very rare.

Okay. Most of the time we’re going to shrink wrap that entire tooth. And now we have a cervical cuff where, when we light cure, the shrinkage of the composite, most composites shrink 2%, two and a half, something like that. That shrink is, it is actually in a way it’s, it’s even better. We’re like locking in on this, on this thing, strangle it, right.

It’s locking in on it, right. And now at least we have a continuous bulk of material that we haven’t layered. Completely ensconcing. That’s a David Clark word that I didn’t know. Ensconcing. Wow. What a word. The entire, what a word. Okay. Yeah. David uses a lot of words like that. We, I, I had a dictionary I was going to look up on my phone.

This is not a real word. He’s making this up. And then I would look up the word that he uses. And it is a word, and I think, I guess, I don’t know.

[Jaz]
Very intelligent man.

[David]
Very intelligent man. It’s my first and only.

It’s, it is a monoblock. Essentially, you’re making this beautiful monoblock, which is, which, which is why you get a, a, a strong restoration. And, and I know Marco and everyone talks about the, the strength. because of the fact that you’re not layering and you have them on a block, that gives you added strength and less risk of chipping at the contact areas posteriorly, for example.

Correct. And maybe we give up 20 percent on the cosmetics, but we gain, we gain a lot of strength and we gain a lot of integrity to that restoration.

[Jaz]
So what’s your concept of choice anteriorly where, where aesthetics is more important. You’re in a posteriorly, you said you’re using the bulk fill paste. Is it a different protocol anteriorly? And then also I want to know. Because Protruserati starting to be thinking this all over the world. How many degrees Celsius, and Fahrenheit if you want, are we heating that composite to?

[David]
So the BioClear heater I think is set to 155, 153 or 155 Fahrenheit. So I don’t know what that is in Celsius.

[Jaz]
It is 68. 3 Celsius.

[David]
Okay, okay. So that’s the heater now and we get questions all the time. Can I use another heater? Can I don’t have a problem with other heaters as long as you can get what you want out of that heater. So, you know the bowl of water in the microwave and all that. I don’t know That’s, that’s stretching it a little bit, right?

[Jaz]
So, the old keeping the local anesthetic in your pockets as you walk around and when you need it, it’s already warm. Have you heard of that one?

[David]
Yeah, I didn’t know about that. I didn’t know about that.

[Jaz]
That’s a real thing. I’ve never done it. Never will, but all I know is that some dentists are very noisy when they’re walking up the stairs and now you know why.

[David]
Laughter Yeah, so, I think. The heating is critical that the heater be reliable, and the one thing I will say, the heaters from BioClear, they are expensive, however, they are very durable.

So, we have the original heater that we bought 8 years ago, we still are using that same heater. And, so, a question we get, which you bring up very good is when do we put the composite in the heater? When do we take it out of the heater? Do you know? So we leave the heaters on pretty much all day, but we only put the composite in about 8 or 10 minutes ahead of the procedure.

So when I’m giving anesthesia, Diana asked me, which composite do you want, right? And then we put it in the heater then the reason is, is I feel like if the heater is sitting in there, if the composites in the heater all day, all day, all day, I think it has a tendency is going to dry it out and it’s going to have a tendency to possibly dry it out now with Filtek, Filtek Supreme, one of the Filtek’s, which actually the one that I don’t use, that was the one that was tested and FDA approved in the United States for heating, multiple heatings, multiple, because 3M, in order to, for 3M to really back BioClear, they were very, very strict on the science. Okay, because it’s a huge, huge company, and they don’t like, you know, trouble.

[Jaz]
That’s very respectable.

[David]
Yeah, it’s very, yeah. So they went into the, they went for full FDA clearance on heating and, and multiple cycles of heating the composite, okay? So, what’s interesting is the composite that they went through, I don’t know if they ever went through it on the blue colored Filtek Supreme, the one with the blue label.

But they did it on the one with the pink label, which was like Filtek Universal or something like that. So the problem that I, I didn’t like Filtek Universal heated, it became too runny. So this is a key thing with dentists who are going to play with materials in the heaters. You need to know how the heating is going to affect the body composite.

Okay, we use all body shade. So if we’re using with Filtek Supreme, we might say, okay, A1 flow, A1B or A1 flow, B1B. Okay, so we’re going to go the flowable and the body composite, very compatible. They can be one shade off, but not more than that. Because if you try to get too fancy. You get a swirling effect of, you might get a little, like a little candy cane too.

[Jaz]
Streaky, yeah, yeah. I can imagine that.

[David]
Streaky looking tooth, right? I have some cases like that because I thought I was going to get real cute, and I was going to put, oh, I’ll put a little A3 in the gingival, and then I’ll, and then I’ll paint the A1. Yeah, you get a nice candy cane. Okay, that does. Don’t do that.

Don’t do that. Okay. So make sure they’re at least the same shade or maybe they can be one shade apart. That’s it. So we do a lot of Filtek Supreme on our routine restorations. However, being a Tif Qureshi fan, I found myself going to Venus and trying Venus because I know he had already vetted, he had already vetted Venus and you know, Tif has been the, my idol as far as record keeping, the way he documents his cases, six-year recall, nine year recall.

You know, and so, we’ll have cases where we mix BioClear and Edge Bonding. And so, we’ll do Venus, I used to do Venus Diamond, now I’ve kind of shifted over to Venus Pearl. So I’m using Venus Pearl in the anterior quite a bit.

[Jaz]
But a lot sTifer. I mean, you obviously, it sounds like you’d like the sTifer composite based on what you said about the previous comment about the Filtek. And I’m at the moment, I’m using Estelite and Estelite heated is very nice and soft. I quite like it, but having used a Venus before, yeah, I found it a bit sTifer when I’m doing heated composite technique to bond my lithium disilicate overlays and stuff. I found that perhaps that was too sTif, but maybe for, maybe because you got enough of the bond and the flowable in there, that for BioClear, you’re saying that it works well in your hands, right? And that’s one of the certified ones?

[David]
Yeah, well, I say Venus Pearl works good in the heater. I don’t think it’s certified, I don’t think it’s tested for multiple heating, so it’s not cleared as far as that, as far as FDA goes. But if you’re going to, Venus Diamond is too thick. Venus Diamond is nice on edge bonding if you like a heavy, heavy composite.

Yeah, and Venus Diamond is very strong and Venus Diamond appears to be quite color stable. But for Venus Diamond, you have to take time because that material is very heavy. And you have to take the time to really blend it and blend it and blend it. And it’s a little tougher on the polishing sequence. So BioClear has a polishing sequence which is really fast and furious and you and you get a luster real quick.

However, that polishing sequence is not as effective on Venus Diamond. On Venus Diamond, you have to kind of go with the Venus polishing, you know, their sequence, because it takes a little bit more time. Venus Pearl is more like Filtek Supreme. When it heats, it heats exactly like Filtek Supreme Universal.

Almost same consistency, same flow, which is what you want. When you’re going injection molding around anterior teeth, you don’t want it too thick and you don’t want it too thin. You want it just right. You know, you want it so that it’s heavy enough to push the flowable, but not so thick that it’s not traveling and needs to travel and conform.

It needs to conform inside that matrices. You know, yeah, venus diamond was just kind of heavy and kind of displacing the matrices too much-

[Jaz]
Which is one of the edge bonding scenarios, like you said.

[David]
Yeah, I like venus diamond for edge bonding. And although I have played around with the pearl now for edge bonding, and it’s actually nice as well.

It’s nice. And I’ve also done edge bonding with Filtek Supreme and Filtek Supreme handles good for edge bonding to not heated for the edge bonding. I don’t do the edge bonding heated. I do edge bonding, not heated. and injection molding heated. So the, basically, that’s a question I get. Which bonding do I do that’s not heated? Edge bonding.

[Jaz]
Got it.

[David]
Pretty much everything else I do is heated.

[Jaz]
Yeah, I’m very much the same. Final few questions as we’re going to wrap up is, when you’re doing your anterior cases, any tips on, I know with the upgrade in the system, it might become easier now, but before there was a bit of guesswork involved in terms of, okay, which matrix should I use in terms of the different colors, different curvatures that you have at the cervical, how has the system evolved to simplify the process so that when you’re selecting, you know, the distal central, you know exactly which one to go for. I see a really cool gauge that that is around. Tell us about when you’re picking the matrix itself.

[David]
Okay. So one of besides becoming an enamel assassin, I also have a reputation as being the lazy BioClear dentist. Okay. So I’m either assassinating enamel or being, or being lazy. So, I use black triangle matrices a lot.

They are a bit more expensive. But I use them for class threes, class four composites, and stuff like that. On the black triangle series of matrices, they have a kit. That comes large and small matrices, okay? And then the gauge tells you the curvature. And then literally there’s a thing in there like a cookbook, right?

So you can follow the cookbook. So what I would recommend for all your listeners is try to find an intro class where you are, okay? Because we teach remote intro class. And so we are online for about now, we call it an intro class, but it’s, you know, David Clark style, which is there’s no such thing as intro at David Clark.

You’re either in or you’re out. Right? So our intro class is about eight hours long on Zoom. And then BioClear mails you all the stuff and you follow along. Now, however, on your side of the pond. They can only mail it one way. So if you take our intro class from over where you are, you’re going to have to buy the heater and the instruments and stuff that goes with it.

And that’s going to be roughly about 2, 000 US in order to take that class. However, I will say I think it’s the best intro class there is. I can’t imagine an intro class like this. And even people that are happy with some of their composite, they always tell me, you know, I like my class two system, but I learned like three or four things that I’m going to start doing right away.

Because, you know, like I didn’t know about the diamond wedges. I didn’t know the diamond wedges came in two lengths because you could have short and long now for like big teeth. That’s, you know, I didn’t know how you use the disc to finish. I didn’t know this. So, because we’re doing, we’re demoing and they have all their hands on stuff.

So if you can get an intro class on your side, then by all means go for it. And there’s learning centers. You have a learning center in the UK. You have one in Sweden. You have Marco in Egypt, Abdul Rahman in Egypt. You have Marco in Italy. So you have a reason to take a vacation to Italy and try to go take, right?

Okay, you have a reason there and everyone wants to go to Italy anyway. So, right. Everyone wants to go. I want to go. I want to go. I’m going to go take Marco’s class for sure because I got to go to Italy.

[Jaz]
Come with us in June. Come with us in June. We’re doing Vertical 3. 0 in Sicily. You should come.

[David]
I should. I should. No, I really should. I’m going to talk, I should talk to Marco about that because I do want to take his course. So once you take the intro class, you have some hands on experience. Now you at least have a feel for it. Now what I would do is go on to YouTube and watch every black triangle video you can find on YouTube.

All right and order the black triangle kit. Okay, so the black triangle kit will come with the different sizes. It comes with the measuring gauge to measure the size of the triangles and all that kind of stuff. And then I want your listeners to follow about five criteria because I want them to slam dunk their first cases, all right?

I don’t want them to go astray, all right? And one of the keys is case selection. Just like you’re starting to learn ortho, you’re not taking the deep bite, you know? You’re not taking the, you know, the cross bites. You want to learn ortho one step at a time, right? So with BioClear, black triangles is not a bad way to start.

It’s not a bad way. You have to use rubber dam. You have to. This is one of the things that we learned. The infinity margin comes much easier with the rubber dam because the rubber dam is helping to form that seal around the matrices. The matrices goes into the gingival attachment. Okay. So it’s kind of tucking in there, but that rubber dam is acting like a gasket, like a turtleneck sweater around that matrices and keeping, keeping things stable.

Okay. Okay. Cool. So you have to use rubber dam. You have to bio blast the case. There’s no option there because you cannot clean between lower anterior teeth with a scaler and think that you’re going to be okay because you’re not going to be okay.

[Jaz]
How about in those tighter contacts? To, to use like an interproximal IPR kind of strip to remove some calculus or biofilm where even the sand might not reach. Is that, is that a part of the protocol?

[David]
100%. That’s part of the protocol. We do have to alter those contacts if they’re tight. So, first criteria I say, Jaz, is I want the teeth to have contacts. So, on your early cases, don’t try diastema closures on lower anteriors and things like that. Got it. Okay, there’s a way.

[Jaz]
So go for black triangle, but not for black triangle and diastemas, obviously, or just diastemas, basically, because it’s a there’s a lower hanging fruit in black triangles.

[David]
Correct. Correct. We’re going to go for the lower hanging fruit right away. So we’re going to have contacts on the teeth, alright? The teeth should have a decent color, alright? Don’t try to color shift too far. So if you have to bleach the teeth, bleach the teeth, but the teeth should have a nice color. Okay? Another thing is good tissue health. They can have black triangles, but we have learned that if the tissues look angry Don’t do bio clear.

[Jaz]
No, that’s a bloody mess waiting to happen.

[David]
Don’t do, don’t try it. Don’t do it. We had a couple cases. We thought you know, hey, we know what we’re doing. We’re good. We’re above all that. No, no, no don’t, don’t do it.

Okay. So what we see in our cases is that if the tissue health is good and you do bioclear, if anything, when you nail the results and the infinity edge looks beautiful on x ray, the tissues, if anything, look better. Maybe it’s an illusion because the papilla is filled in. Whatever it is, but it seems like the tissues even look better, and the patients say, I don’t get as much tartar as I used to, I don’t collect as much food in there, you know, I don’t have to kill myself with a water pick every night, and I have less sensitivity, and all the great things happen. When the tissues look angry, the opposite happens. When the tissues look angry and you do BioClear, the tissues get more angry.

[Jaz]
Mm hmm. Mm hmm.

[David]
They were unhappy before and now they’re really mad. Okay? The patient bleeds like crazy, so don’t do that. So, stable tissue health is good, or get the tissue health. Good. You know? If the tissue health looks bad, sometimes I just send them to the periodontist and I say, when the periodontist tells you that you’re okay to come back, you come back and I will do it, but right now I can’t do it, alright? And the patient knows that you’re not desperate for money, you’re not starving to death.

Right? Now, mentally stable patient, that’s hard to judge on a brand new patient, but you would like to try, for those who are learning this, try it on a patient of a record who has been in your practice for a while. Like Tif Qureshi says, he says, he gets more nervous on a new patient. Everyone wants new patients. He says he would rather work on an old patient because he knows them. And he knows their behavior. He’s a hundred percent correct. A thousand percent correct.

[Jaz]
He’s a lie. It’s all about the lifetime patient, which is why we, we love Tif so much. Absolutely.

[David]
Yeah. He’s a hundred percent correct. And by the way, if you’re, if your listeners haven’t learned from Tif Qureshi in the UK, you have, you have a BioClear Learning Center there and you have Tif Qureshi and ISA Ortho, and now you have you. And you have Jaz. You guys are getting spoiled over there. You guys are really getting spoiled.

[Jaz]
That’s crazy.

[David]
So don’t be lazy like me. You have to go after everything you have to go take a BioClear course and then go take an ISA Ortho and then take another BioClear and then take an ISA Ortho.

And trust me, you will never regret either one of those learning experiences because you’re going to grow and grow and grow and you’re going to grow faster and that’s going to lower your stress level. I tell people if you could learn 80 percent of what’s in David Clark’s head and 80 percent of what’s in Tif Qureshi’s head, you would be one of the best dentists in the world.

If you could just get 80%. Which I’m not sure you can, but if you can go, if that’s set your goal and say I’m going to get 80 percent of what David Clark has and I’m going to get 80 percent of what Tif Qureshi has. And sure, I’m going to go learn from John Kois and Frank Spear and, and all these other people, but I’m going to go after these, these people, right? And so let’s go back. I did, I digress.

[Jaz]
I loved it. That’s fine.

[David]
All right. Mentally stable patient, contacts are good, good tissue health, good color on the teeth and generally good alignment. So if the patient needs ortho, do the ortho because The BioClear matrices, the black triangle matrices, they don’t line up so good on teeth that are misaligned.

And that’s more advanced. If you’re going to handle teeth that are all crooked, then the matrices are not going to because what happens is these matrices have a nice area that they butt up against each other, and they kind of stabilize each other. We call it like matrices stabilization. And we like matrices that are stable.

I don’t like matrices that are swimming around. My, my criteria is I need to be able to go have a cup of coffee and come back and everything should be sitting right where I left it. That’s a stable matrices and that’s a stable patient. And we spend, Jaz, we will spend on a lower anterior case all morning. If we have four anterior teeth, we book all morning long. And sometimes on some patients, I have not even injected my first tooth. Until I’m two hours into it.

[Jaz]
There’s the preparation, the cleaning, the isolation. That’s the foundation, isn’t it, really? The actual injection molding from the videos I’ve seen is very seamless and the cutting back is quite rapid. I’ve seen that. But it’s the setup, the setting yourself up for success.

[David]
The setup. If you’re doing indirect cases, you’re setting up your technician, you’re trying to set up your technician for a slam dunk and you’re doing everything you can to make it as good as you can for the technician. When you’re doing direct cases, you’re setting yourself up and you have to take the time to set that case up.

So to win, it’s got to look like a winner before you inject your first tooth. And if it looks like a winner, it’s going to be a winner. If you’ve got a good feeling about it, it’s going to go the way you think. Mind you, the size of the triangles is not that critical that if it’s a big triangle, small triangle, that doesn’t make any much difference.

Okay, so just try to follow those five criteria of just trying to have a stable patient, stable periodontium. Okay, decent color, good contacts, and good alignment, and follow the cookbook and you’ll be, you’ll be okay. Good isolation, rubber dam is going to happen, you know.

[Jaz]
I wish Diana can clone herself and start doing rubber dam for, for all the doctors. You’re very lucky, David. You’re very spoiled. Okay. So that’s great. It’s been absolutely amazing. We’ve got a two part episode. I’m just so excited to share this with all the Protruserati. I think we’ve covered this is exactly what I wanted. I didn’t want to become too much about the product, I wanted to become about the science, the engineering, the philosophy, and I think we covered that.

But I also want to shed light on a fantastic product that does exist, that makes our life easier. And it’s a system, it’s a philosophy, and it’s about being exposed to everything wonderful that’s out there in dentistry and finding your own path. And this is where part of the path, part of what we did today was exactly that.

For those that would like to learn more from you guys, can you please tell you, obviously, I’m going to put in the show notes, the QR code and the link. I would love for everyone to follow you as well. Both of you but how, what’s the quickest and best way for them to, to reach out and find your stuff.

By the way, if you’re on Protrusive Guidance, David is on there. We’re on Protrusive Guidance. There’s a, we’ve got, we’ve invested a lot of time and money and energy into. Now creating the ability that you could actually DM me. You can DM David. You can DM anyone on there. And it’s so seamless. It’s way better than Facebook.

So join Protrusive Guidance, protrusive.app. Then go and message David and tell David what an epic job he did. And what your favorite part was about this episode. I would love for you guys to do that. So reach out to David on the DMs on protrusive guidance, but how can we reach out to you? How can we learn more from you?

[David]
So Diana, how did they find you for, or they’re definitely not asking me rubber damn tips. I can tell you that they’re definitely not asking me that question. So how did they find you?

[Diana]  
I have my instagram account. That is rdhdianamckenna and always there. So I’m happy to answer any questions.

[David]
So Diana McKenna, how do you spell McKenna?

[Diana]  
M C K E N N A Irish last name.

[Jaz]
I’ll put that, very nice, I’ll put that in the show notes as well so people can just click onto it.

[David]
Yeah, she doesn’t look Irish, but she’s got some Irish blood.

[Jaz]
How about you, David? How can we follow? I’ve seen your wonderful work before. How can we follow you? And then what’s the official website to learn more about training with you guys?

[David]
Anybody that wants to learn more in general about BioClear is bioclearmatrix. com, bioclearmatrix. com. And then that brings up the front page of the site. And then you can go to resources there and that’s how you can get in touch with, and it should be international. You should be able to find the learning centers in Sweden or UK, or you and I are going to go to Italy.

Go visit Marco. So, but if you want to reach me on Instagram, it’s carrolldentistry, C A R R O L L, two R’s, two L’s, caroldentistry, F L, like Florida. Yeah. Okay, because we’re here in Miami.

[Jaz]
What a wonderful life decision you made to, to, to live in Miami. you always think about, we don’t spend enough time in our lives deciding where you want to actually spend the rest of your life.

Where do you actually want to live? And I feel like if you’re someone who resides in Miami, you, you picked well, so amazing. It’s great to host you guys today. I had a lot of fun, lots of geeky discussions that were had, and I just really want to thank you for your time and enlightening us and sharing some, some really cool things.

And also making yourself vulnerable, talking about the things like failures and the tough cases you had, your first case. And sometimes when things didn’t go to plan. That’s what makes our community of dentists special. The fact that we’re not all perfect, we’re happy to have a little bit of a laugh, happy to learn from our failures, and happy to just expose ourselves a bit.

One thing, this is the first time I’m revealing this. One thing I’d like to do, family willing and, and stuff, we’ve got two young boys and stuff. I’d love to host a conference on where, where we have people just like you, David, just amazing dentists that we respect. Just do an hour each, just show your failures and what you learn.

It’s just, it’s, it’s, it’s, it’s no humble brag, just show all your cock ups. And that’s one thing that it will probably happen this year or next year. I would love for that to happen, basically.

[David]
Yeah, I would be honored, Jaz. And, and, and Diana and I are honored to be on this show. I’ve seen the quality of the clinicians that you interview all the time, and we are very honored to be here, and we would love to help the Protruserati any way we can.

[Jaz]
Amazing. Well, we’ll be sure to DM you what we learned and engage with you on the Protrusive Guidance. Thank you so much.

[David]
Thank you, Jaz.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end. I’ve hopefully whet your appetite for the anterior segment of this episode that we’ll cover next week.

Now, as you know, I’ve been recently giving you the CPD questions and I give you one as a teaser, but I’m actually really late because I need to go to work. And also I’ve got the flight tomorrow and I’ve got some family time to catch up with. So just to let you know, there is 45 minutes of CPD available from protrusive. app, aka Protrusive Guidance.

I just want to thank David and Diana again, but again, they’ll be back next week to finish off the part two, which we focus more. on anteriors, how do you bond to root dentine? Like if you’re closing black triangles, you’re going to be a root dentine, right? So that’s one of the themes that we cover.

As ever, I want to thank my team, Erika, Gian, Krissel, and Mari were involved in this one. And if there’s one action you take by the end of this episode, if you’re enjoying the last episode in this episode, and you enjoy and enjoy it adhesive month, please could you share it with a friend, I’d really appreciate if you could spread the word of Protrusive.

Thanks so much for listening all the way to the end. Once again, I’ll catch you same time, same place next week. Bye for now.