JAN 12TH 2024.docx

So what we're going to start with is we're going to go back to the impression materials we talked about last time. These are sort of a list of characteristics we've made. I don't think we need to read through them. Again. The main takeaway with all of that and that sort of exercise of thinking about...

So what we're going to start with is we're going to go back to the impression materials we talked about last time. These are sort of a list of characteristics we've made. I don't think we need to read through them. Again. The main takeaway with all of that and that sort of exercise of thinking about materials and talking about them from my point of view, and I hope yours was the idea that if you start to start to think about what you need materials to do for you, and then you look at what they actually do, you can generally pick out the things that are going to work for you. And in our case, we had a long list of characteristics we'd like. And after looking at them, we figured out that for the most part, our PVS materials are poly ethers do a pretty good job in the realm of elastic materials of hitting, you know, say, checking off most of the boxes. And they varied, of course, but it does give you some flexibility to choose materials for different purposes. We also, in having that discussion, talked about where. Digital scanning is going to also or say optical scanning however you want to perceive. It is also going to check off a lot of the boxes for us. So that also is a plus. And you can see those are the choices we're going to make. So let's talk about tissue management because that's very important to us in class so far when you've been scanning. All you've had to do is scan. You haven't had to manage tissue unless you put your finish lines where they didn't belong. Remember, we asked you to put the finish lines of your preparations a little above the tissue. We wanted you to stay one half to one millimeter away from the tissue, which should make scanning very easy because there's no tissue to manage. If it was a clinical setting and you had your finish line as you do in lab. All you would do is scan it. The only thing you would worry about clinically would be to try to get a dry field. So in our clinic, what we have for you are these devices a suction device called Mr. Thirsty? It's probably been described in operative. Yeah. So it's a device you sort of attach to the high speed of actuator. You stick it in the patient's mouth on one end, they're biting down on it. So it's kind of a mouth prop. And on the other end it isolates that quadrant. It suctions. And it should make it fairly easy to keep a fairly dry field. And with your air water syringe, you can just dry off the tooth. If you're super gingival just scan it. It's a breeze. There's reasons. Dentists. Love, absolutely love the all ceramic materials because they make it less necessary for us to hide finish lines. And if we don't have to hide finish lines, if we don't have to hide margins of crowns, our lives are easier. So if for nothing but our own selfish reasons, it's nice to stay super gingival when we can. He. As you are aware of, there are reasons why we do go so gingerly without rehashing those. Um, the thing to be aware of is that, unfortunately for us, most of the teeth we prepare when we're doing crowns are not ideal. Perfect teeth on a tripod. Right. You've done crowns. You don't crown a tooth because it's perfect. You crown a tooth because it's got all kinds of things wrong with it. And part of what goes wrong with the tooth is very often that there was old decay, which so often is at or below the gingiva, which means if we're going to make a crown, we have a finish line for our prep beyond the end of where that old restorative material was on healthy sound to structure. And if we're sub gingival doing that, then we have to get into the realm of tissue management, where we have to make sure that we can obtain the, you know, kind of clean, dry field to either scan or make an elastic impression. So let's talk about the way we do tissue management. The most common thing we're going to do. Is used. Retraction cords. Right. That you've probably. I'm guessing most of you have probably done this before. This is the technique we're going to use overwhelmingly in the clinic here at Bu. Right. So when you start to talk about retraction cords. So these are for those of you who perhaps haven't used these, they're basically little tiny strings in varying diameters. And they're made up in different ways. But these little strings are tucked around the gingiva to physically push it aside a little bit. And that's how they work. It's, you know, a very basic technique. It's just a kind of blunt instrument, if you want to call it that. When we do cords, typically we do them in what's called a single cord technique or a two cord or double cord technique. Okay. So in just a minute I'm going to show you a little diagram of what that might mean. So we'll talk more about those techniques in a second. Before getting into that though, let's talk about how we manage the physical cord. So the court itself here at Bu comes in what would be described as either a knit cord or a braided cord. And that just has to do with how the little strings. How the cord is put together and there's different ways it's done here. We choose those two sort of designs because the faculty likes them. The more old fashioned version of cord is a braided cord, although before that the even more old fashioned thing was Dennis took a little cotton and they twisted it in their fingers and made their own little strings. That was the most old fashion. And then companies started making it for us, and typically it was braided. And now, and this is not that recent, you can have a net cord. The advantage of a net cord is that it actually has a lot more space in it. So it's fluffier. Now that works two ways for you. Some of you may look at the difference between what would be, say, a number one rated cord and a number one net cord. And what it might look like to you is that the net cord looks twice as big in diameter. And it is until you start to press it into the tissue, into the sulcus, at which point it collapses because it's got a lot more air in the knitted fibers. So you have both of those available. When you go to use those, you might choose one or another for a couple of reasons. One reason you might choose is that the instructor says to you, go get this or that cord and let's use that. And that would probably be because that's what they like to use. So just, you know, to be transparent, what I use essentially 100% of the time is a net cord. The reason I use it is I think it's better, obviously. The reason I like it better is that the night court is softer. It's more pliable. So one of the challenges for those of you who have not placed retraction cord. And for those of you who have placed it, this will ring true. One of the challenges of Cord is that as you tuck it into place, tuck it against the sulcus into the sulcus. What happens is it kind of twists and turns and pieces of it go this way or the other. It doesn't just sit there completely limp, which is what you'd like it to do, especially if it's braided. Braided cords are going to have a little more sort of firmness to them. So as you start tucking it in one place, the extra part is sort of, you know, twisting off in another direction. So it's frankly harder to control. The net cord because it's softer as you tuck it into place. I find it easier to manage. The other thing I like about the net cord is that when we use these, we're going to typically soak the cord in a hemostatic agent, the net cord, because there's more space in it. It essentially is going to more easily hold or absorb the hemostatic agent. Right now if you have a situation where the tissues in perfect health. Right being sub gingival and you don't abrade the tissue as you refining the prep at the end. So everything is just terrific. You could argue at that point that there's no need for a hemostatic agent for something to stop bleeding. If you place the cord carefully and the tissue is very healthy, perhaps you wouldn't initiate bleeding and it would be fine. But between you and me, how often does that happen? Right in our dreams, right? It happens. If you wanted to try placing chord on your type of don. Because your patient in the lab won't bleed no matter how hard you poke them. But real patients who actually have real blood and real tissue, it's more in our dreams than not. So as a general rule, I would suggest that anytime you're going to place cord, the cord needs to be wet. You don't want to place dry cords because dry cord, when it hits tissue is going to start to want to suck fluid out of the tissue, which could help initiate bleeding. So you want a wet cord at a minimum soaked with water. But more frequently, the sort of default setting when you're using cord is to soak it in some sort of a hemostatic agent. The reason you do that is that almost always you need to stop bleeding. Either because you caused it by refining your prep and scratching the tissue, or because the tissue wasn't perfectly healthy. So as soon as you start tucking a little cord along it, it starts to bleed. A lot of times our students and I'm not going to include you because you haven't done this in the clinic yet. So it's those bad students in the past. And no, I'm just kidding. Not bad. But you know, when we make preps and we temper tooth, you know, our our characteristic approach to doing crowns in the clinic is typically going to do a preliminary prep and Tem patient goes home. Mostly. You know, most people don't work so fast. Prep temp impression is a lot to do in a three hour session for most of our students. So if you're going to just prep and temp and you make a temp that doesn't have really beautiful marginal adaptation, so you leave overhangs. What happens. Patient comes back a week later. You pull the temp off and the tissue wants to bleed. It's inflamed, it's irritated, and part of it is caused by us. You know, by leaving a poorly fitted temporary. One of the reasons. That in our class we spend so much time sort of when we're grading your temps, talking to you about marginal adaptation is it's so critical because so often you have a finished line below tissue, you have a margin below tissue, you have a temporary blue tissue. And if you make a bad margin, you make it bad for yourself and the patient the next visit, whether that next visit is an impression, whether the next visit is trying to insert a crown. And in situations where the crown we're trying to insert is to go further with this is something like Emax, where we want to physically bonded to the tooth. So now we really need a dry field. If you pull that temp off and it just starts gushing blood, how hard is it going to be to ever get that cemented? All of a sudden you're back to really working hard to control the bleeding and isolate the field and get it under control and get the, you know, you just make it really difficult to succeed. So, you know, every step matters. Things like proper marginal adaptation, proper contours on our temporaries can really matter. And that's where. So with our default notion that we're going to be placing cord, and we're going to basically always want to soak the cord in a hemostatic agent upstairs in the clinic, we're going to have two different agents available for you. We're going to have something called viscous clear. And we're going to have humidity. And the difference between them is basically in two areas one. The viscosity has a higher concentration of aluminum chloride. That. If you want something to stop bleeding. Do you want more of the coagulant or less? More so. Of these two agents, which is probably the better choice. This cassette. Make it stop bleeding, right? The other difference between them, besides this being a higher concentration is it's viscous, right? It's sort of thick. It's not quite a gel, but it's very thick. That's a big advantage too, because and I don't know if any of you have done this, but. Has anyone here ever tasted aluminum chloride? Has anyone ever had any of these things in their mouth? Anyone? How bad did it taste? It's real bad. It's really bad, right? This stuff tastes horrible. Whenever you use these things, one of the first things you typically do is you tell the patient you're putting something around their tooth, and you're going to try your best to keep it from them, tasting it. But chances are they're going to taste of it at some point and it tastes awful. Don't be surprised. It's going to taste terrible. It's going to taste like it's poisoning you. It won't. We're not using enough for that. But it's going to taste like it because it's awful. So another advantage of the viscous clear is that because it's viscous as you go to place it, it's going to be less likely to flow all over the mouth. So all that being said, what I'm obviously leading up to is if you're working with me in the clinic, I'm going to tell you to get a piece of the net cord and we're going to get some viscous tat. We're not going to use the braided cord or. Because we're going to use something that I think is easier for you to place, and we're going to use something that's going to be less awful for the patient and more effective at stopping bleeding. Those are the choices I typically would make. So those are what we have available. Um, and this stuff works amazingly well. For those of you who've used these things in the past, you may have experienced this for anyone who hasn't. It's unbelievable how effective these are at stopping bleeding. We can have a situation where somebody had a temporary that fit really, really horribly. Or perhaps they just prepped way some gingival that day really hacked up the tissue. It's bleeding like mad. You place this, you let it sit for a few minutes, you pull it out, place another, you know, let it sit for another few minutes, pull it out. Bleeding stopped. It's incredible. It's really wonderful stuff. So for Dennis, it's great. And the fact that it's so incredibly good is one of the reasons we're never in our school going to use epinephrine. So cords, you may have used these yourself in the past. You may have seen them. You might be aware of them. It's a common enough thing where the manufacturers make the cord, and the cord has epinephrine in it. Epinephrine causes contraction of, you know, capillaries. It stops bleeding. That's great. The only problem with an epinephrine so cord is that they're not perfectly reliable in terms of how much epinephrine is in every bit of the cord. So if you got really unlucky and you had a cord that had, say, a high concentration in that little bit you had and your patient perhaps, you know, was apt to react more than some others to epinephrine. You tuck it in there and the next thing you know, the patient is telling you how they don't feel well and they feel like their hands are shaking, they're feeling jittery, and they feel like their heart's racing and something is wrong and they're really not comfortable. Can they sit up? Uh, could they have a cup of water? You know, and now it's a problem. So. The way we see it here at Bu. Is that why risk? Any issue with that? There's no reason to because these materials are so effective at stopping bleeding that there's no reason to add a layer of risk of getting the patient to have a reaction to the epinephrine. Okay. So we're never going to use those right now. Um, let's talk about these really quickly. And then we'll talk more about placing cord okay. So there's a lot of different ways you can manage tissue. And there's going to be more than what I've got here too. But let's talk about them for a minute. It's always about getting the tissue out of the way so that the impression or the scan, either one, effectively they're the same, can capture the finish line properly so that, you know, you have captured the tooth effectively. So a putty wash technique is something some of you may have done in the past. In its standard form. What it involves is making a preliminary impression. You know, in the mouth. Uh, with a heavy body material, whether it's just a heavy body that you inject out of a gun or it's a putty, you physically mix in your hand, place it in the tray. In the traditional technique, you put a little piece of cellophane in the tray over the material seated in the mouth. Let it set, pull it out. And now you pull off that piece of cellophane and you have sort of a an indent where all the teeth were but a little room around all the teeth. And then the way the technique would work is you'd put a light body material as you wash into that same tray where that indent was all the way around, squish it into the mouth, and the pressure, the hydrostatic pressure of that light body material being shoved by the heavy body material tightly against the teeth, theoretically will displace tissue, and in theory, might even displace blood and capture your impression. You can also do the putty wash technique by doing that initial impression and then taking a burn, grinding out some room where you want to add the wash material. The light body material, uh, in our clinic would be you probably find none of the faculty who will ever recommend this. But it's a technique. And then there's a lot of variations of this technique where people even drill holes in the sides of trays and start injecting, like, body material around teeth and all sorts of things. But that's one sort of approach. Things like expresso or accident. And there's other materials like this. These are materials that come in varying forms, whether they're in one form. It's physically a clay that has a hemostatic agent in it, and it's designed with a special syringe for you to squirt that into the sulcus around the tooth, and so that that clay will physically push the tissue aside. And the hemostatic agent, after it's left for a few minutes will stop the bleeding. Um, others are kind of a gel that you might squirt around the tooth. Some of them, they work in various techniques. It's all different things manufacturers come up with. Uh, one technique, you squirt the gel that has a hemostatic agent around the tooth into the sulcus, and then you seat a little kind of cotton, sort of plug over it to push it into the tissue and have the patient bite down, let it sit for a few minutes, you pull it out, and in theory, it'll all pull out at that point. Once it's set with stuff like this, you just wash the putty away and now the tissue before it would have time to collapse back, should have a wide open sulcus so you can inject your material or scan, capture the tooth as you would like to. So and there's other versions of these things. Um, this is a similar thing, which is kind of a material that comes with a little syringe. You just sort of stick it in the sulcus, squirt it around. In theory, it's viscous enough to push the tissue aside. You let it sit for a few minutes. And again peel it out of there and make an impression. Any of these techniques can work perfectly well. As everything in life is. It just requires a learning curve and practicing the technique. So if you're walking around Yankee at the end of the month, so you're in there on Saturday, you're walking around, you go past or I don't know which I don't remember who makes ginger track. You're walking by there and you see a display and they say, oh, here you can take a sample because you tell them you're dental student, right? They'll be like, oh, here, take a sample. Try it. Because, you know, they're thinking maybe you like it. And the next thing you know, you'll be buying it, right? And you come to the clinic and if the instructor doesn't mind, you can try it. And perhaps you say, this is the greatest thing I've ever done. I hate packing cord. I find it difficult. I'd rather do this. It's all you know. Any of these techniques are fine. It's a matter of learning the technique and getting good at it. What you find. And you may have already experienced this yourselves in the past, with whatever dental practice you did, where you had techniques you liked. Change it? No. If it works, you just keep doing it. You know, at times dentistry can be boring because you do the same thing over and over. How it is, you know? But that's okay because you're just looking for predictable results. So Ginger track again. It's a little different than these. It's one where you, you basically put a little tiny tip on a syringe into the sulcus and displace tissue. Other ways of managing tissue. Old fashioned was an electro surgery device. So this was a little device that had a tiny tip on it. You would stick that around the tooth and run it around there. It would have a little electric current and burn away some tissue. Theoretically, as it burned away the tissue, it would also cauterize the tissue so the bleeding would stop. Fine. Problem with electro surge. If you weren't careful and you got anywhere, say too close to the bone down below, or all of a sudden, you know, it's, um, get some necrosis. It made a mess. But you could use it effectively in many dentists did for years. The laser is a more modern technique where you take the tip of the laser, a soft tissue laser, go around, you know, the sulcus around your finish line, burn away a little trough of tissue, make your impression, put your temp on. And typically, by the time the patient comes back, the tissue is healed beautifully. Theory, tissue heals beautifully after using a soft tissue laser. In our clinic, we do have them available, but if you ever have a situation where that seems to make sense and the instructor you're working with says, let's use the laser, you're going to have to find one of the perio instructors. They're going to have to make a whole point of getting the laser. Bring it, setting it up. It's a whole production. In clinical practice. If you have a soft tissue laser in your operatory, it can be very quick and convenient. So you may have used these. You may choose to do these in the future. The only downside to a laser compared to a cord is you can buy a lot of cord for the cost of a laser. In the long run, who knows what the better investment is? But that's up to you. Okay, so, um, let's go ahead and look a little bit at how we play sports because as I said at Bu, what you're going to do over and over again when you need to manage tissue is you're going to use cords. So the first thing about retraction cord and this is actually going to apply, say to using a laser or something, is that when you place your cord this green is going to represent cord in the drawing I made. And the red obviously is tissue. So we're looking down on a preparation. When you look at the cord that you've placed you have to see the cord. If you can't see cord. Which would mean you've tucked the cord under the tissue and now the tissue has flopped back over it. You won't get an impression. Right? Because if you're looking down and you just see tissue, what will happen when you remove the cord to make the impression? Well, the tissue will be right where it is. So you'll inject material and you won't capture this. You'll just capture tissue. You might have made a space, but it's not where you need it. You haven't retracted the tissue properly for your purposes. So a simple rule to remember is when you look down, you need to see the cord. Now, the nice thing about the cords we use is they all have color to them. They typically come in various shades. They're easy to see. So you have to look down and see cord. Now we talked about single quarter dual cord single quarter double cord technique right. When you do these the key thing is you place whatever you like better. But you have to place it properly. So to start with a single cord technique essentially this is what you're trying to do. You're trying to choose a cord of a diameter that's adequate. That as you tuck it in here adjacent to the finish line, that it's pushed the tissue aside enough. That when you remove this, you'll have a space here that you can inject your material and easily capture both the finish line and some uncut tooth. We always are going to look to see beyond the finish line. That's how we know that we actually captured the whole finish line. So if you choose too small a cord, you won't get proper tissue retraction. Or you might call it tissue deflection. If you have a larger cord than you need, you could obtain the tissue retraction you want. But it's harder to place because if you have a fairly small sulcus and you're trying to shove a giant cord in there, that's hard to do. So it's really up to you to try to choose the appropriate sized cord. As a general rule, because I'm trying to protect the tissue. I'm going to like the smallest cord that will get the job done. But at the same time, you don't want to have two smaller cord. It won't work for you. That's the essential idea of the single chord. You place it around the tooth adjacent to your finish line so that as you look down you can see it that the tissues displaced. You let it sit with the hemostatic agent long enough for the bleeding to stop. You don't want to leave it for, you know, 20 minutes. It's the sort of thing you place, and in a few minutes it should get the bleeding under control. And if there's so much bleeding that it won't, you'll typically pull the cord, rinse it off, and then place cord again with the hemostatic agent to get it under control. But that's your basic approach there. Now the dual chord technique or double chord technique. You'll have a smaller cord and then a larger cord. A lot of dentists like this technique. Essentially, what you're trying to do with a dual chord is place a lower one that's down into the sulcus, and it has to be lower down than the finish line itself. It has to be clear of the finish line. You place a larger chord over it. You let those sit, and then when you're going to make the impression, you pull out the outer chord. So this is removed. This stays behind. Dennis like it because those who like it believe you can get a little more retraction this way. They also like the fact that by leaving this behind, they believe that there's less chance of new bleeding starting up so that they can obtain a better impression. Um, either technique is fine. What I would recommend is that you probably try both techniques when you get to the clinic. If you haven't used these in the past, you might also be guided by whatever instructor you're working with, because instructors are typically going to have a preference. And so if the instructor says, you might say, well, how do you want me to pack cord? You know, I've been doing dual cords. Doctor who likes a single chord might say, well, let's try with a single chord so you can see the difference. Now again, I always try to tell you what I do. So you know. And I can explain why I choose certain things. I habitually do a single chord technique. The reason I do it is I feel like I'm being less abusive to the tissue than shoving something farther down. I actually have basically never seen the need for the second chord. And what I don't like about the dual cord. Besides whatever extra abuse I do to the tissue. And there being no need. The other reason I don't like the dual chord is there's always a little risk with it that as you pull out your outer cord because these fibers, you know, these are, you know, there's fibers to both chords. If this sort of sticks to it a little bit. So as I pull this out, this one tugs partway out, which might be hard for me to see at that very moment. Sometimes you might make an impression, and now you capture an impression of the chord along your finish line, as opposed to the chord tucked way down. So I personally, primarily because I don't find for myself a need for two chords. I don't do that. But when you get to the clinic, a lot of the instructors are going to prefer that technique, and that's fine. It's worth trying. They both can work well. Now, having said all that, what I should tell you, though, is there's plenty of times when I'm working and perhaps there's a spot where it's a little deeper under the tissue than others, typically in approximately, and I really could use a little more than just that one chord. So what I do in those situations is one of two things. Most of the time, what I'll have is a chord that perhaps is a little longer than I needed. So I tuck it all the way around the tooth, and then that extra little bit I double over in that deep spot. I'm still going to pull out the entire cord when I make the impression. But in effect, I've done a double chord where I could use it. Other times, I might cut a separate little piece of cord and double pack a certain area, knowing that I have to remove everything before the impression. And in situations where perhaps there's really a lot of bleeding. What I'll do after I place my cord is often I'll take a cotton pellet, soak it in the viscose, start and tuck a bunch of cotton pellet in there with the viscous. Let that sit for a couple minutes to really get a lot of the viscous presence. Stop the bleeding. So there's the main thing to to take away from what I'm just describing is no matter what technique you do in dentistry, no matter how you visualize something as your standard approach, your ideal approach, your typical every time approach. It doesn't mean you shouldn't be ready to adapt and alter that approach, because there are times where what you're presented with in the mouth is a little different than typical. So. Manage it. Just do whatever you have to do to make that work right. That's the key thing. So those are the approaches I like to take with these with chords. And. But you will see both the key thing to be aware of because students forget this all the time, is that whatever technique you use, you do have to remove the cord that would be present. Where the finish line is, because if you don't remove the cord, that's going to be a disaster because then you just make an impression of cord, which is no good to you. You're back to doing it again after. Any questions about that before we go on? Great. Okay. So when you're going to do this, the next step is if you're going to do a physical impression, an elastic impression, you have to inject material. Along that finish line, you have to capture it. And the point of these drawings is to say you want to stick the syringe. You want to inject it where you actually want it to go. So if you want to capture this, put the tip where you want to capture. Don't put it somewhere vaguely near there and assume that it's going to flow where you want it to go. So you're going to tuck this tip right against your finish line and you're going to go around the tooth. We're going to look at some slides in a minute of doing this. But you're going to go around the tooth twice at least. The reason you do that, and you want a steady pressure of material flowing out the whole way, because if you don't do it twice, sometimes you started going and you trap a little air bubble. If you went around it once and you trapped a little air bubble right on your finish line, the impression won't be any good. So by going around twice, what you're hoping to do with the second layer is to push that first layer out of the way, taking away any little air bubbles you've trapped. So after you've done this, you're going to let the material set. You're going to remove the impression from the mouth. And then we're going to look at a list of things that you're going to look for to make sure you made a good impression. So this is a basic list. Let's look at it. The first thing is you have to be able to see the entire finish line, and you have to know you capture the whole thing. This applies all all of these things we're talking about apply both to elastic impressions physical impressions versus optical scans. Right. So you have to see the entire finish line. And part of the way you know you've captured it is you have to see some uncut tooth beyond it all the way around the tooth. You don't have to see, you know, two millimeters of uncut tooth, you know, just a tiny, you know, a quarter of a millimeter of uncut tooth. As long as you can see clearly there was a finish line and something beyond it, you're okay, but you have to see some uncut tooth. There can't be any bubbles at all on your finish line. That's the most critical part of the impression you're trying to capture the finish line itself. So if you have bubbles there, it's no good. Just go ahead and do it again. On the prep itself. You say the body of the prep or the occlusal surface of the prep. If you have a little tiny bubble or two, fine. You know, it can be poured the lab conflict that off. It's not a problem. But if you have a lot of your prep missing, that's a problem. So no gross voids on the prep. You have to capture your neighboring teeth. Remember, you need contacts with your crown. So if you don't capture those, well, can't make a crown. When we used to hand mix material. Um, which isn't that long ago, but when we used to hand mixed material, a lot of times if you didn't mix it really well, there'd be streaks visible. And what that represented was imperfectly mixed material, which meant those were areas where you could get distortion if the material weren't set properly because it wasn't properly mixed. So as a rule, you still want to make sure you don't have streaks. When we're using auto mixing machines or auto mixing guns, it should be very, very rare that the material doesn't mix properly. And yet it can still happen. There are times when we use these devices and for whatever reason, something about the gun we're using or the the tube of material we're using, it doesn't come out perfectly from both sides. And you look at the material as it comes out and you can see that it doesn't look quite right. And if that ever happens, you can assume then at that point the material hasn't gone, you know, isn't going to set properly, it's not going to work and don't use it. And then the final thing to mention is when you take an impression and you see the tray. And this won't happen very often, but if you're impressing, say, the final tooth in an arch. And you don't position the tray properly so that the inside of the tray presses against the finish line. Well, that's an area where the impression will be wrong. It'll be distorted. You make an impression, and on the occlusal surface of the crown, you could see it shows through on the inside of the tray. You don't really care because that can be managed in the lab. But finish lines, you can't really correct those with certainty. And that's the most important part of the crown, right? The margin. So you can't have shutters on your finish lines. These make sense for everyone okay. All right. Let's talk a drop about impression materials just to make things really clear for you and why it mattered. So we were talking before about materials, some being hydrophilic as an ideal versus hydrophobic. So if you have a hydrophobic material and you put a drop of water on it. What happens. It makes a bubble like beads up just like this. If you drop water onto something that's really hydrophilic, what happens? It just flows. Like, for instance, if you drop, um, water into water, it just sort of flows and disappears. If you drop, say, oil into water, it separates. So if your impression material is hydrophobic. This is going to matter to us in a little bit, because when we pour our model, it's harder to pour a model. In a hydrophobic material, because the stone won't flow as well because the stone is mixed with water. So as a way of illustrating this, here's a cross section of an impression. Right? So now we're looking into the impression you can see. Here's the tissue. Here's the uncut tooth. Here's our finish line right. Here's our prep. When we go to pour into that. Pouring our stone in there. Right? The stone is going to kind of flow along, and depending on the impression material we have, it's going to either flow beating up quite a lot or it may flow very. Smoothly. And that affects how easily you can capture things without a problem. So if you have a hydrophilic material, it's going to fill these sharp little spots very easily. Whereas if you have a hydrophobic material, because of the way this beads up, it's very easy for it to jump past a little spot on a finish line, on the margin you're interested in, and easily have gaps where you don't want them. So just as important as it is to make a good, sharp, accurate impression, it's every bit as critical that when you pour it, you don't ruin the nice impression you made by pouring it badly. Now there's things we do when we have a hydrophobic material, we can spray it with something called the bubble iser. It's basically a surfactant to make the surface a little less hydrophobic. But you have to be very careful pouring these. So this is again one of those skills. You practice it, the more you do it, the better you'll get at it. All right. Any questions about those things before we move on to other things. Great. Okay, let me, um, let me do two things here. Let's get rid of that and let's do this. Work. Wait a second. All right, let's do this. So let's do attendance right now. Here's your attendance thing. Let's do our our attendance and then we'll go on to something else. SPEAKER 1 It's like. SPEAKER 0 Are you guys doing with that? Is it working? SPEAKER 1 I. So. Actually. Hey! Hold on. SPEAKER 0 Somebody got. SPEAKER 1 That? I. Oh. I. I think. You guys pretty much there. SPEAKER 0 All right, let's go. SPEAKER 1 On. Right? Yeah. All right. SPEAKER 0 So let's go back to what we're doing here. Let's go through some stuff of actually making an impression real quick. So here we have a prepared tooth. We want to make an impression of it. So remember never forget this. It's really critical. Always make sure you have the correct occlusal reduction. Double check that a lot. It's one of those things that's easy to forget. So we're going to check that our occlusion looks right. We're going to place our cord. What I want you to see here is you see cord right. You want to be able to see the cord all the way around. What we're doing in this view is a little clinical trick you might like to do. Where we had these preliminary preps, there were attempts in the mouth for a while. We're ready now to make a final preparation and impression. It's a good idea very often to place your cord and then use the cord itself to protect the tissue as you refine the finish line. Or it can be a nice idea to take some sort of instrument, and it would typically be one you designate just for this purpose, because it'll get hacked up very quickly. But you take something like a plastic instrument. And what I try to do when I do this is I actually set it on top of the cord and sort of pull the cord down a little and so that as I refine the prep, if I scratch anything, it's the instrument. And I also don't accidentally pull the cord out with the diamond, so you can do that as a way to refine that. So I'm going to run through really quickly, sort of the old fashioned impression with the stuff we mix up, and then we're going to look at something more reasonable. The key thing here is if we're going to make a poly ether impression, you must use poly ether adhesive. If you're going to make a PVS impression, you must use PVS adhesive. These work in stock trays, but part of the way they work is that that adhesive makes them fuze to the tray. If you have the wrong adhesive, they don't fuze properly and the ability to have distortion grows right. The materials aren't meant to be used without a tray, and they're not meant to be used without adhesive. If you're going to do like and this is we're going to look at just sort of a hand mixed technique real quick. If you're using a disposable cheap syringe, which you might choose because they're cheap. The key thing to watch out for is very often they're manufactured badly, which means there may be little bits of flash of plastic at the end. So if you're buying cheap syringes, make sure these are clear, because if not, when you squirt material out, that's going to create a little kind of gap, a little ribbon in it which is just trapping air. So if the tip of the syringe is not sharp and clean, cut it. Make sure it is. We're going to just look at hand mixing real quick. Regular body light, body material. You put out equal lengths when you hand mix. You guys may have done this in the past. You may not. The point of this is there's a right way and a wrong way to do things. This is a right way. The materials are all together. Catalyst and base, easy to mix. This is wrong in a lot of ways by spreading separate groups around a pad. If you're ever in a situation where you have to hand mix, you're going to take a lot of time gathering this together to mix it. So by the time you're ready to use it, the light body material has been in the mouth too long already. It's like everything's out of order. The other thing that's wrong here is the catalyst has been placed right on the base. If that sits for more than a moment before you start mixing, it's already starting to set where it touches. So you could create areas that could have distortion. So when you're going to do this you're just going to gather them together, mix them to kind of a smooth consistency. There should be no streaks. They have to be completely mixed. If you're using this kind of thing you're just going to back load it, scrape it along. And the other thing to notice here is if you're using a disposable syringe that has a straight tip, will take your finger and curl it so that you can put the tip of it where you want it to go. Now this goes back to what we spoke about earlier. When you're going to place the material, choose where you'd like to begin. Typically, you're going to begin in whatever spot you think is most likely to be difficult to capture. So if there's somewhere that's deep in a proximal stick, the tip right in there to start. And go around the tooth completely around the tooth, injecting steadily the whole way. You want positive pressure twice. First time around to kind of capture everything. The second time, if there were any bubbles captured to displace them, cover the whole tooth with your light body material. In the meantime, your assistant mixes your heavy body material. They load your tray, you seated in the mouth. Let it set. Now in terms of using any materials in the mouth, there's one thing I want to mention to you, because we see students do this at times and it infuriates the faculty. When you see the tray of an impression material in the patient's mouth. You. The dentist holds it the whole time till it sets. Upper. Lower. It doesn't matter. Seated. Ideally, you'll sit the patient up at that point. And hold it in place. Watch the clock. The reason you hold it in place yourself is that it's possible. Along the way, the patient finds themselves in some distress, especially with upper impressions. And what we see students do at times, and it's rare, but we do see it and it makes the instructors. You know, this is one of those things where like, you know, if I could throw you out of this school right now, this is what I'd want to, you know, we see students where they'll they'll be doing an upper impression, they'll seat the tray and they'll tell the patient, here, just hold that. And then the students poking around the space, you know, like, oh, let me get out some. I want to do a relight on my temple, let me get it ready. And oh, and, you know, and or worse yet, you know, they're in their operatory going, I do some messaging while I'm waiting. You know, that's not just stupid, it's dangerous. You know, if the patient starts gagging or starts having distress, having problems starts choking on their saliva, you're not in position to manage it as effectively as if you're holding it yourself. So it's up to you to do these things properly. Excuse me. So seated. Hold it. You may already know this, but one of the things if you're holding it, typically you want to do impressions where you're sort of positioned behind the patient and the reason you want to be that way. Is that if the patient does start to have maybe a little tendency to gag or something, they're feeling uncomfortable. There's things you can do that help. One of those things we do is we say, well, lean your head forward. And if the patient's getting nervous and they're getting hysterical, well, you've got them in a headlock. So you can lean their head forward. Now that sounds a little crude and it sounds aggressive. And yet for patience, the fact that you're holding it is reassuring. It's helpful to them that somebody is in control in this scary situation. Other little tricks. You may know these about impression making for gags. You ask them to like you know, while they're sitting there. Lift. Lift your left leg. No. Lift it up as high as you can. Hold it, hold it, hold it. Oh, you can't hold it longer. All right, lift the right leg. You do things to distract them. There's all kinds of tricks, but you being in position to hold it and make sure everything's under control is the most critical thing. So you let it sit there till it sets, take it out and then look at the impression. So we had a list of things we look for to make certain impressions. Good. Right. We have to see. So this prep happened to have a bevel on it. But we have to see uncut to structure all the way around the tooth. Right. The finish line could have no bubbles, no gross voids on the prep the neighboring teeth while impressed no streaks. No show thrus on our finish lines. Good impression. Okay. If you like, you might want to box it or you might not. What I would recommend is at first, when you're first using whatever materials that you're using, I would go and ask Jerry. Have you guys met Jerry? Yes. He's lectured. Jerry's going to lecture again next week, covering like the next step of things with all the lab stuff. But go to Jerry's lab and ask them. You know, you might say, I haven't poured this material before. Could you help me? They want to make sure it comes out right the first time too, right? So you'll go ahead and you'll pour it and Jerry or, you know, we'll help you with that. All right. We're going to look now at making an impression using another technique. We're going to use a PVS material. So we have well here it's vinyl polyester but it's the same thing. You're going to use the correct adhesive in your stock tray. And we're going to use an auto mixing machine. A regular or heavy body material is going to be mixed by this machine, and we're going to inject the light body material out of an auto mixing gun. This machine is different than the one we use in our clinic, but that doesn't have any particular relevance. The only thing about this machine that's worth noting, and a lot of them are like this. It has a timer built into it. So if you have a material that requires, say, 2.5 minutes in the mouth to set and you have some working time, you can set a timer for whatever you think the total amount of time will be. So once you start, it'll begin counting down and it'll ring. It'll tell you when it's time to remove it, as opposed to you watching the clock. That's imperfect in one way. You may have already seen this, but what you'll find in a place like Boston. We're in the winter. It's very cold and in the summer it's very warm. These materials, like just about everything else, change in heat or cold. So this time of year, when we go to do these, if the materials are supposed to set, say in two minutes and 15 seconds, it's not. It takes longer. And you might say, well, shouldn't the operatory always be about the same, say, 72 degrees? And the answer is, yeah, it is. But somehow or another, that overall atmospheric condition does affect things. So they'll set faster in the summer. They'll set slower in the winter. So your assistant is going to just squirt the material out of the machine. They just press the button. In our clinic, you'll do the same thing. Choose somewhere to start. Get the material of the flow around if you're doing an upper impression for fixed. We don't care about the palate, so don't fill the palate because our goal is not to choke the patient. It's to capture the impression we're interested in. So just make a horseshoe of material. And that's going to be ready to use. We're going to use an auto mixing gun. They're typically going to be with a specific tip. Theoretically. And in practice this works pretty well. By the time the material comes out of here, it's fully mixed. You're going to put a little injection tip on there so you can put it where you want it to go. If you've used these before, you probably are aware that they're fairly easy to use. If all you've used is a hand syringe before the first time you try to do this, it may seem awkward to you that you're holding this whole gun, but as you get used to any of these things, they work fine. It's just a matter of practice. So we're going to go into the mouth. We're going to. Now, actually, one thing I might not have stressed before, if you have caught in place before you do any of the mixing, you're going to rinse off the cord real well to wash away any of the viscous start or hemostat you've used. So you have to wash it all out real well. You're going to dry it. You're going to make sure you have your cotton pliers in your bag so you can grab it. And then you're going to be ready to go ahead. So you say to your assistant you can start mixing or loading the tray. You grab your cotton pliers, you pull out your cord carefully, and then you grab your gun and you squirt around the tooth along that finish line two times around the tooth. So here's a clinical impression using a PVS material. As we talked about last week. They come in bright colors. They look nice. They can taste nice. This is a material happens to be called honey gum. In theory, it tastes like honey. In practice, it kind of tastes like nothing. It smells a little bit like honey once it's set. But look at our impressions. So we have a chamfer finish line, kind of a deep chamfer. We have our finish line captured. Well what we can see no bubbles. Right. We have uncut two structure all the way around past the finish line. We have no gross voids on the preps. Right. Our neighbors are well impressed. We have no streaks. The only different colors are the light body material and the regular body material. We have no show thrus on our finish line. We have a good impression. Same as always. Same rules. Here's another clinical example just to look at right. We can see our finish lines. We can see our uncut two structure. Beyond. Right. Okay. And then you're going to take that and you're going to let it, um, set appropriately. Go ahead and get it out of the mouth, clean it off, disinfect it. Um, and then you'll be ready to pour it. When we talked about these materials. Before you pour this, there are certain things, um, with the PVS materials. I don't know how much we spoke about this last week. From what I recall, with PVS materials, traditionally they release hydrogen as they set. If you pour them too soon. You can end up with a model that has thousands of tiny bubbles on its surface from the hydrogen. Current materials have scavengers in them to try to capture most of that gas. Bless you in practice, though. You have to make sure you've read the directions, because some of these materials are made to be poured in a half hour, some of them in an hour. In some ways, you never go wrong leaving them even longer. Except that typically we're all in a hurry all the time. So if you're going to pour it yourself, you have to make sure you wait long enough so that you don't accidentally pour too soon and end up with a bad a bad model. Um, we're going to stop with this material right here at this point because Jerry's going to pick up talking about what's involved in pouring them, making models and dyes next week. So do you have any questions about that before? SPEAKER 1 All right. SPEAKER 0 Of the PVS materials. Polyvinyl selections. Uh, as a rule. Release hydrogen. And that can be. A problem for us. I have a model I can show you. I think it's, um. I don't know if I have it in this stuff for lab, but I'll look so you can see what it looks like when you pull them too soon. All right. So as I said to you at the start of class today, I want to spend a few minutes looking at some clinical stuff too, because we're going to do that whenever we have time, which I think can enhance what we're doing. So here's a radiograph. And if you look at this, you can see something here that doesn't look quite right on these two teeth. Right. So what do you think we're seeing? So, like, what's going on here? Just cervical burnout? No. Is it carries. SPEAKER 1 Margin. SPEAKER 0 I think this is the prep they were doing, and they didn't capture it in their impression. And they made a crown that fit here. What do you think this is? What do you think? Is it part. SPEAKER 1 Of the prep? SPEAKER 0 I say, I think I agree with what's being set up here. I think when they prep this crown, the dentist cut this out here, which he shouldn't have. We'll say he, because women would be too careful not to do this and hurt somebody. I don't mean to be sexist, but that's that's a positive. Men are much more, you know, aggressive. I don't know, you know, I don't have time to make sure I didn't hack up the neighboring tooth. Patient will survive. They've had endo. They won't feel it. Great. I think what happened is the dentist was very sloppy working here and and did this with a burr, so that's not good. You should avoid doing those things. Get a lot done. Yeah, yeah. Don't do it. Yeah. If you do those things, do it intentionally. And you'd probably have to have a good reason in some particular, um. Uh, animosity towards that patient that's between you and that. So here's a patient, um, who presents in the office like this. All right. It's a young woman. She's in her 20s, uh, late 20s. Um, here's her smile. All right, so what do we see happening here? Missing laterals. Right? So the most common missing teeth other than third molars. Right. Missing laterals. She's missing laterals. And first thing I have to tell you, this is a bunch of years old. This. And that's important because increasingly orthodontists nowadays understand that if a patient has congenitally missing laterals, you don't really want to take the canines and pull them into the lateral position. What we like to do better for the patient is to keep the canines where they belong, maintain the spaces. And then later placed dental implants where those laterals should have been, right? That's better. But some years ago, it was much more common for an orthodontist to bring the canines into that position. So now there were no spaces. We didn't have implants way back, and depending on how old fashioned the orthodontist used to be, that's what they did. So this patient presented this way. And she's grown up now, and this is what her smile looks like. And her chief complaint is she doesn't like the look of her smile. This doesn't look right to her. Is she reasonable to not like it? Sure. Right? Absolutely. So. There's a couple other views. Is the canine on one side, the canine on the other? This is the view from above. All right. And so one of the challenges of this kind of problem in terms of what do you do about it. Is canines don't look like laterals, do they? They don't look like laterals, both in their dimension, their width. They don't look like laterals in their basic shape, and they certainly don't look like laterals. When you look down on them, right, there are different cross-section, so that there's going to be a real canine eminence, you know, on the tissues, on the bone. They're just not shaped right for our purposes. So if the patient comes in and says, can we make these look like laterals? The answer is you kind of can't really. Problem. So this patient. This patient just to tell you more about them so we can discuss how we might treatment plan them. The other things to know about the patient. So I said, it's a young woman in her late 20s, and, um, the patient is by profession. She's an engineer. Now I bring that up because in my experience with patients, that can be a really good thing or it could be a really bad thing. Now, let me ask you. Do any of you have either? Well, hopefully not yourselves, but do any of you have people in your family or friends who are engineers? Okay. So. All right. Just between us. They're a little different than normal people, right? SPEAKER 1 Yeah. SPEAKER 0 They're different. Right? Now, I don't know the the answer to this question because I've wondered about this as long as I've been in dentistry. I never met engineers as patients. I don't know whether engineers are born that way or whether they're just made that way when they go to engineering school. But I do know, or maybe it's both, but I do know that engineers and this, as I said, it can be either really good or really bad. They have a need to understand things. In a deeper, more granular way. Then the rest of us. And if some of you are engineers by training before dental school, you know it's okay. It's not a bad thing. Chances are, it helps you to be even a better dentist because you really have to understand, which could help you to be a better dentist. As patients, though like I said, it can be really good or bad. The way it's really good is people who want to understand. Things can be great patients because engineers are typically going to be very smart, right? They're thoughtful. And like I said, they need to understand. So if you have an engineer and you say, well, here's what's going on in your mouth, this is why it looks the way it does. You can discuss it with them and you can have a really, you know, useful discussion. And as a dentist, one of the things I think we all want is to make treatment plans for our patients that suit that patient in an ideal way. So, you know, I might look at a patient and I have certain ideas of what I think ought to be done. But that might not be right for that person. So what you really want to do is inform the patient, you know, make sure they understand the different options that exist, the pros and cons of each option, and with any luck, if they understand well. Whatever they might choose is the right choice for them. The key for you is the dentist. At least how I conceptualize this is as long as I'm presenting them with options that are all sound, that are all appropriate. Then it's okay. They might choose something that I wouldn't choose for my mouth, but that could be all right, because as long as they understand, it could still be the best thing for them. So in that respect, an engineer can be fantastic because as you have that discussion of different options for treatment, they're going to make sure they understand because they have to, you know, engineers can't exist without understanding. So you have that discussion and then you can really make the best informed choice for that patient. All right. Those are the good engineers. As long as we're talking about types of patients there is that other side of engineers. And they're not just bad engineers. And I don't mean in terms of the quality of the engineering. I mean the quality of them is dental patients, right? It doesn't mean they're bad humans. They're just they can be the worst dental patients there are. I think of them as evil engineers because because I think there seems to be some horrible, malevolent thing going on behind the scenes that ruins my life, that they're they're evil engineers are evil. Because there's never that last question. They never understand it enough to suit them. They just keep picking at it and finding some other irrelevant thing to ask about and keep poking. And they make it impossible to do the effective treatment planning. You want to do the opposite of the good engineers, where you kind of get to an understanding and you're ready to go. And those evil engineers. I don't know how they function at work because they probably keep going that way too. So they're probably the ones who get assigned to do the, um. Like in a software company, they're probably the ones who have to pick apart the software and make it fail. You know, so they irritate all the other engineers who made the software in it. What's that? I was sorry. They do? So then they really are evil. Yeah. So. But in all seriousness, and I'm not. I don't mean to make fun of engineers, I really don't. But in all seriousness, different patients are going to present with different personalities. And in the case like I'm describing, some of these people are going to try to drive you insane. They just don't stop. And yet the ones who, you know, are just trying to come to the right conclusion for them, who are sort of you can reach a conclusion. They're fantastic. So the good news about this patient, though, is she's a good engineer. She's not going to drive us crazy. She's terrific. She's smart. She understands things. So as we talk about this, let me ask you, what are the options for her? What can we do to fix this? All right, I heard extractions. SPEAKER 1 All right. All right. SPEAKER 0 It's a it's a legitimate. It's a legitimate option. What else? Ortho I heard ortho. What else? Veneers I heard what else can we do? So when you say smile design, you're talking about what? All right. So really be near the whole front. Make her look really good. What else? We could crown her, right? What else can we do? So I've heard. I've heard veneers, I've heard crowns. I've heard ortho, I've heard extractions. What else can you do? Is there anything else you could do for her? So let me ask you. I'm looking for one other idea. So what do you guys do in here on Tuesdays? Composites. Could you do bonding? SPEAKER 1 Yeah. SPEAKER 0 Maybe. Yeah. All right, so let's consider the different ideas we have. What would be the most conservative, at least first thought, most conservative approach. Ortho. Right. So if there was a way to move things around and make the spaces we needed to then place implants, that would be the most conservative. Yeah. Okay, so ortho won't be the next most conservative approach. The composites. Right. So we're just going to focus on the couple few spots where the shapes are wrong and stuff and do composite. What would be the next most conservative veneers. Right. And then probably crowning the teeth and then finally extracting teeth and placing some implants. So. Well, you know what? Those are the things we talked about because those are the options. I'm not sure I offered her extractions. I could be honest. I don't think we did. But I said it's a few years ago, so that might have seemed really radical. But anyways, so we talked about these different things. And what do you think she chose to look into as her first option for ortho? Because she's. SPEAKER 2 Perfect point of view. UNKNOWN Catch up on that retainer. SPEAKER 2 Um and in. UNKNOWN Can throw a few. SPEAKER 2 By compressing. UNKNOWN Yeah. That is. SPEAKER 0 That's terrible. Sorry, it won't work. So here's the answer. An orthodontist knows that that's not going to work, right. But we talked to the patient about it, and it sounds like an option. Right. Until you talk to the orthodontist and they go, well, here's the problem. There's nowhere to put these teeth. If I want to move this tooth, I have to extract this. And that's not conservative. So the patient though at the time we said so where I start as a default on a lot of things where teeth are in the wrong places, a lot of times I start with, well, the most conservative thing we can do, if your teeth are just crooked or twisted or something is rather than do a prosthetic solution, it might be to just put the teeth where they belong. So a lot of times we start with ortho consults to see if there's a solution. She wanted to do that. So she saw an orthodontist who said, the only way we could do this is going to be to start taking out teeth, because there's nowhere to put them, which so orthodontists know these things. The rest of us may not be as sure of it. So the author was not an option for us. Thank you. So. You're right. No, but you're right. But but again, when you when you treatment plan, a lot of times you say, all right, what are all the things we might be able to do? SPEAKER 2 What we usually tell. Hey, this is like one of. UNKNOWN And road is very difficult to. SPEAKER 0 So that's a that's a really good description. You should all remember that if you're talking like so you have people in your practice little kids and they're missing some teeth like this that, you know, because this is how you, you know, how you get things right. Because you learn stuff from your colleagues. Right? So you say, I mean, that's a great description. You just walked down the right side path. Yeah. There's no way to turn around and come back. That's good, I like that. Um, so she years ago with her parents, the orthodontist, they went down a certain path and there's no coming back. So if we can't do ortho. What did she choose to do next? So why did you choose composites? SPEAKER 1 All right. SPEAKER 0 It's very conservative. Price and price is one option. So what if she didn't care about the price? What did you choose? What if, but how? How do you know she didn't use composites anyways? So anyways, you know. What she chose. So she's an engineer. She's smart. We consider all the present cons. If we do composites, can we go down a different road later? Yeah, yeah. All right, we can. So actually, what she chose to try was composites. We said, what's there to lose? At worst, we don't like the result, in which case we do veneers because that would be the next least invasive approach. So you can see how this is shaped and that this isn't as bad. So that's not as much of a worry. But we're going to have to do something here. So we decided we would try composites. So what we did is we're contoured the facials of both those teeth first to try to bring them into the arch form. So here we are. Those are reshaped a little bit. So it got closer into the arch form we want to go with. Now you'll see in a little bit there's other problems with all this. SPEAKER 1 Right. SPEAKER 0 And then we're going to put some composite on the teeth. Okay. So we're going to try to make this this one's going to be more successful because it's a smaller tooth. And the way it was rotated and stuff. Right. So we put some composites on these and we're going to close the diaspora a little bit. All right. And we end up with this. Okay. Now, is that ideal? No it isn't. The color canines are darker than the other teeth, right? SPEAKER 1 Yeah. SPEAKER 0 Couldn't really fix that. So this is where we get with the composite. So. What do you do then? You hand the patient a mirror and they look at it. So here's the question for you. Now, this was done a few years ago. What happened next? All right. How many people think she walked away and said, this is fine for me? How many people say we had to take go ahead and veneer all the teeth? Well, for what it's worth, here's the interesting. I mean, I don't know how interesting this is, how the story ends at this point. She looks at this, said, this looks great. This. This seemed at that moment to have solved the problem she had. These looked like a normal smile. She wasn't really concerned at the time with the discrepancy in color. I think. Closing the door, I asked him for help to. She was happy. So off she went. And, um. And as I said, this is some years ago. And somewhere along the line, I don't know, she she moved away and I have no idea what happened. I would guess at this point where it's been a lot of years ago, I would bet almost anything. Somewhere along the line she had the teeth veneered. Let me ask you a separate question while we talk about veneers. If she comes to you now and says, you know, these bombings were done years ago. I was okay with them for a while, but the color is not great, and I think this could all be made to look better. Um, how many teeth do we want to veneer? I see four. I heard six. I hear six, I hear eight. So when I say how many we want to veneer, there's two different ways to think of it. One might be how much do we want a veneer? SPEAKER 3 This trial of the patient. SPEAKER 1 I mean, you know. SPEAKER 0 We have mortgages to pay. We've got all this staff got to pay their paychecks, got to buy supplies. Or how many teeth do we want to veneer? Like get the job done. So how many do we need to veneer? SPEAKER 1 Almost eight. SPEAKER 0 All right. This is a good answer up here. How many does she want? Right. So what I would say and again everyone approaches things differently. I personally approach these things always with what's the least that might get the job done. So part of the discussion at that point is going to be how much do these two first premolars look to her, like appropriately shaped canine teeth? If she's happy with those, I would just veneer the four front teeth. If she says, oh no, I don't. These have to change. I've been looking at pictures online of smiles and I can tell these don't look quite right. Then we might have to do six. I don't think we would do more than six though. But if we could get away with four, that's probably where I would tend to stop veneers, as you know, um, you know, from Doctor Cataldo, veneers would offer us a pretty good ability to change the color, alter the size and shape of these a little bit. Not that much. We don't we don't have that much room to really change that. But we could we could make some serious improvement, even it up quite a lot. So they probably could be a very nice solution. That's where that ended up. Anyone have other questions or or comments? All right, so this is where it finished. Um, just a couple of the views. That was her before and after. So, you know, as we look at that, you know, obviously, I would say even with the color of these wrong and the size and stuff that looks better than this. So I suppose when she looked, she was happy. So that that made it at the time successful. One of the things I think I've said to you other times is to me, if the patient is happy with what they're seeing or how it functions, then I'm happy to. You know, I don't always find myself needing to get done with this and say, hey, you know what? The color of these isn't right. We're going to have to do something different if they're happy that that made it work. There was a question. SPEAKER 1 Oh. SPEAKER 0 The question was asked is how did I bond this with the retainer there? And, um, to be honest, I don't really remember, I might have. It was a few years ago. I may have just removed that power post, because that's what that is. It's a power post that, uh, internal, you know, uh, a splint. I might have just cut it out of their bonded. Um, I don't remember if I had done that, whether I put the power post back or not. So I think that's probably what I did because it would be hard really to. Yeah, it's a good question. SPEAKER 1 Okay. SPEAKER 0 Yeah, yeah. That's fair. Um, no, I mean, that's fair. Uh, the interesting thing is every patient is different. And so one of those questions for each of our patients, and this comes up a lot when you're the word smile design came up. One of those issues that that comes up a lot with patients is going to be do they want smiles that look like some sort of imagined perfect, which can vary patient by patient because some patients, their imagined perfect smile is almost like the way a child draws a smile. You know? You know, you make the mouth shape and you draw a line through the middle and a bunch of lines like this. And there's these white blocks, and that's what they think a smile is. Other patients are more sophisticated about it. There are patients. So patients who want what they think of as a perfectly glowing white ideal. And then there's other patients who want what they might think of as a more naturalistic smile. Um, it varies quite a lot. You guys may have different experience of that. Uh, than I would, because in different parts of the world, um, beauty standards for things like smile vary quite a lot. Um, it used to be much more common. You know, if we had patients who we ever saw who were from Europe somewhere, and we used to see a lot of Europeans, um, they were much more comfortable with discoloration and stuff and crowding because they were used to seeing it more in this country. Uh, this is good news for orthodontists in this country. Ortho became almost like a right. You know, the way we might say health care should be a right in this country. Every little child has to have straight teeth. Right. That's why, you know, it's an enlightened country. Because for orthodontists, we think the right way. SPEAKER 1 No it's not. SPEAKER 0 Oh, yeah. Never. Yeah. In the US it's very common now where if you have adults who somehow missed out on ortho as a kid, a lot of them are like desperate whenever they could afford it as an adult to straighten their teeth because, you know, somehow it's like a mark of, I don't know. That's why I decided to come to America. That's right. SPEAKER 1 It's a good choice. SPEAKER 0 It's a good choice, you know, because and the best thing is, we need a lot of orthodontists here because everybody needs straight teeth. It's important. So it's good. Um. Even geriatric patients straighten teeth now. Yeah. Now, I think the good news for orthodontists around the world is that I know that American culture, you know, from Hollywood and stuff does tend to spread around. So for orthodontists who don't move here, probably eventually everyone everywhere else will need straight teeth too. So that'll be good for them. But here in the in the United States, everybody has to have straight teeth. Yeah. It's like you're you're. Look. It's biblical. It's like a mark of Cain that you don't have straight teeth, you know. Well, mother in law's evil anyways, so you know that. So, um, any other comments on that before we we go on? Okay, so here's a patient. SPEAKER 1 You might see. SPEAKER 0 All right. This patient presents okay. And he's, uh. He's a young man. He's in his late 20s also, and he doesn't like his smile. What do you guys think? Do you like his smile? You'd have to be very, very dedicated to the idea of a natural smile for that, right? SPEAKER 2 That's how you are a smile. SPEAKER 1 Right, right. SPEAKER 0 But he's not European. He's American. He's in law school now. He's in his late 20s. He's planning to be a successful attorney. His goal as an attorney is he wants to be a litigator. He wants to go into court, stand in there and talk in the, you know, in public. He wants to talk to juries and judges and whatever. He wants to be a litigator in a courtroom like we watch on TV all the time. He's an interesting character because this again, is a picture from some years ago, and it wasn't that many years ago that not every human on earth had a tattoo. There was a time when not everyone had a tattoo, and so he. SPEAKER 2 But not. SPEAKER 0 He's not an engineer. He's a he's going to be a lawyer. And but he he had a tattoo he wanted to show us that ran down the whole side of his leg of a tiger because he was fierce, you know. So he was he was going to be a fierce litigator and. And that was fierce before Beyonce. So it was a different kind of fierce. And he, um, but he um and like I said, it's a few years ago. I mean, nowadays every patient who walks into your office has tattoos all over them. But he didn't he didn't. He was rare. But the secret was when he was in court in front of the judge, he'd have his, you know, his long pants on his big boy pants. And the judge wouldn't know that he was fierce with his tiger. So. But he wants to look different. So what are our options? We started out before we had options last time. Ortho. Is that an option? Our orthodontist left. So we'll say it is. SPEAKER 1 All right. SPEAKER 0 What's another option. Can we do bonding. All right. Why can't we do bonding? SPEAKER 1 All right. What's the. SPEAKER 0 Problem? If we wanted to bond this. SPEAKER 1 The shade. SPEAKER 0 Bonding isn't great. It really isn't great for hiding color. It's really not. The problem is that if we want to hide this, we're going to have to have, you know, bonding that's this thick on it. You know, he's going to he's going to look very strange. Yeah. So could we do internal bleaching here? That's a good idea. We could try. Do we really think we're going to take that? But it might help. So it's not crazy. So it has risks, right? So bonding. Probably not a great idea. There's a lot we'd have to do a lot of stuff to maybe make bonding work. What about veneers. Can we do those. Better chance. Maybe you had a question. Well, that's we're talking about. Yeah, that's what we're talking about right now. We're looking for options. So we had internal bleaching and composite. You had veneers, crowns. What else can we do for the patient? Extractions and implants. Would we? Are we going to offer him extractions and implants? SPEAKER 1 No. SPEAKER 0 Because remember I said we can offer all the options that are reasonable options. You know most dentists, if we said should we pull out some teeth and do you know implants, most of us would say, no, it's overtreatment. SPEAKER 1 It's wrong. Yeah. Uh. SPEAKER 0 Well, yeah, it's a question of how much you do in my case. No, I told them we can't do that because the first thing every patient who asks you when they come in, every patient walks in with, with crowded teeth, discolored teeth, something wrong with the teeth? The first thing any of them asked you is, can I have bonding? They all know the word. Can I have bonding? And the answer is, more often than not, I discourage it because I personally think it's a very, um, for myself. I think it's an inferior material for certain things. So I think to try to do this with composite will yield up a bad result. There's other reasons. These are endo treated teeth and they're, you know, they have restorations in them and things. So it's probably not a great idea. So we may have talked about veneers a little bit but we may have talked about ortho. Can we can we ask off from ortho. Here's the crowding. Can we offer more ortho. Good. Jump that space, right? Yeah. It's a little bit tight, though. Space is tough, huh? Yeah. It's ugly. So let me. I'll give you guys a tip about the auth0 and whether it was offered to them or not. It was not. And the reason wasn't because I knew that it would be difficult. It was because the dentist who referred him was his, actually his pet Adonis, who happened to also be an orthodontist. So despite him being 28 years old, he was still seeing doctor Mike. SPEAKER 1 So. SPEAKER 0 But he was finally, doctor Mike said, it's time for you to grow up. You have to go to the. You have to leave and go to the big boy dentist. But if doctor Mike, the orthodontist, was willing to do ortho to fix it, he would have. So he told them, we're not going to do ortho. So he he's now at the big boy dentist. He can't have ortho. And we're not going to do, um, we're not going to do bonding because it's too it's too ugly. So what do we do? It's Friday. We're going to do crowns, but not just because it's Friday. These teeth have had endo. It was not a two. It was not a spot really for veneers. These teeth need protection. So notice what we've prepared. Did I prep all four front teeth? SPEAKER 1 No. SPEAKER 0 Prep free teeth. Why did I prep three teeth? Not for. So one idea is that I'm going to veneer that one later. Why else didn't I prep that too? The patient liked the way it looked, right? Or maybe I like the way it looked. The reason I didn't prep that tooth is it's not in cross bite. It's not as rotated as the other. My own feeling was. I thought it looked pretty nice. It's got a little rotation, but I thought it was a very natural looking lateral. I liked it and I always like to do the least dentistry necessary. So I said let's just do these three and we'll make you look great and we'll make the laterals look a little rotated. But that's very natural. You'll have a nice smile. So these are preliminary preparations. Now this preliminary preparation is worth looking at though. So if we go back see how this is rotated. And see the rotation here. The crowding. This is more extreme if we're going to prep this where at the end I want the facial surface of it to be angled like this. What do I need to do here? You need to prep it a lot more, right? So he's in his 20s. What do I have to tell him before I start cutting the tooth? I have to tell him that there's a higher risk of needing root canal treatment than if he was a lot older. You know, there's a risk I have to let him know because I have to overprepare it here. So we prepped the tooth right. And looking from above, you can see that. So here's how it was before. But now I've over prepped it to try to change the angle of the incisal edge. I'm creating an illusion, with the preps going to allow the temp to change the shape. So that's the preliminary prep. You can see all the. These are the old filling materials from the endo that was done years ago. Okay. So the reason I wanted you to see this today, though, is because we're going to make polycarbonate crown forms for temps. Would that be the normal sequence or would I normally have sent out to have temps made in the lab? Normally I'd send it out to the lab because I wanted esthetics in the front of the mouth, but in this case, the patient was just he had to start tomorrow, you know, he had to start as quick as he possibly could. He was really excited. He was that kind of person. He was a guy with everything he ever did was a huge amount of enthusiasm. So the fact that we decided we're going to start treatment, he wanted to start that treatment. Can we do it today? The answer is no. We can't do it today. We ran out of time. We just got done talking. But how quick can I get in? So I said, all right, well, you know what, I can bring you in quick. And I figured I could use the polycarbonate crown forms. So remember last week I mentioned them today you're going to do one. Next week you're going to do one. It'll be a graded exercise. Part of what I want you to grasp is how convenient and powerful a technique it can be for certain circumstances. Once you know how to do it. It's really a great technique. So what we did is we took two of them about a size we thought would be good for the Centrals. They were realigned and as while I rely on them, I fuzed them together with the realign material with the acrylic. But I realigned them and I chose them for with more than length initially, so they were too long. So one of the tricks you do, and you may have already done this in the past, is you take like in dentistry, you know, whether it be you. We're very high tech school, right? We're all digital and stuff. This is one of those high tech tools. It's a Sharpie. But it works. You take a black Sharpie and you color in the incisal edge and hand the patient a mirror. And that's what looks like the length of the tooth. So if the tooth is too long, you colored in however you want. You hand him a mirror and he goes at the right length. If they say yes, then you just take it in the lab and cut it to that length. You can look at things that way. So those are just Sharpies. We said, all right, that's the length we're going to do so that we go back to the lab. We cut them down. They need to be polished still. And then we're going to make a stamp on this tooth again, a polycarbonate. We're going to realign it and connect it to those at the same time. But while doing this one, what I'm going to try to do is create the same rotation. The same angulation is the other lateral to to make it look like it matches. And you see it this way. We got it out of crossbow. Because we're cheating. It's prosthetic solution. So you see the angle of the incisal edge. How those match. So that's made up. It's put in his mouth. And we say, okay, go home and see how you like this. So then he came back not too long after, I don't know, a week or two, whatever we did and. What do you think happened next? He insisted that we had to crown ten as well. You're right. So he looked at it and he said, well, you know what? I like this more robust lateral, more than that one. And he insisted we crown that as well. So we, we took that one and we put a temp on it. And actually somewhere along the line I lost the images of what we did next. So um, ultimately we completed the four front crowns. They were individual crowns, of course, in the end. But um, that was sort of the polycarbonate crown form. So the key thing here is in just a few minutes time, you can frankly temp multiple teeth. It's just a matter of choosing the right dimension of the crown forms, relining them properly and then just trimming them up, shaping them however you'd like. You can customize different parts of them if you want to, you know, create more, um, you know, incisal embraces or whatever you want to do. You can do various things with them. As I said last week, talking about them. The other thing is. If you want, you can make them look a little darker with a darker red line material. You can make them look a little brighter with a lighter red line material. They also have an interesting tendency to blend in surprisingly well, so it can be a very useful technique. It's part of the reason we present it to you, because it can save you a lot of aggravation, especially with front teeth, because it can be difficult to shape the anatomy of front teeth. And they kind of come pre done for you. So they make it very easy. Any questions about that. Yeah. Yeah, we ended up crowning it. SPEAKER 1 So. SPEAKER 0 The question is, why didn't I choose a veneer on that other tooth? And honestly, it's we wanted success. And when I say that, it's that to do these crowns. With whatever material we chose, and I don't recall now to hide the coloration underneath and then veneer this separately. It would have been hard to get like a perfect match. Whereas if we do the Four Crowns together and because the case, you know, yes, that's not as conservative of two structures. So that's a valid concern. But at the same time, this case was in many ways a lot of it about esthetics, especially number ten. So if at the end of it, it has to all match and look great. Sometimes two structures worth sacrificing. You know, for instance. You know, if the only if the paramount thing. Actually, I'm not going to say this. There's a case I hope we get to to show you at some point where sacrificing some two structure really became critical. Just because the only way to achieve the patient's goal. And so you say, all right, we're either either you're never going to get where you want to be, or we're going to actually have to sacrifice some stuff that we normally wouldn't want to sacrifice. And we'll hopefully we'll see that case one of these days. SPEAKER 1 Okay? Yeah. SPEAKER 0 So the question is, can you put a veneer on where you're bonding to the dentin? And the answer is yes. Um, but the bond is stronger on enamel. But in theory it should be strong enough. Yeah. Any other questions before we stop? So anyways, so we're going to go to lab in a little bit. We'll talk a little more about you making these today or one of these. And um, and we'll go on from there. So uh, I have about a quarter of um, a few minutes after ten, ten, ten, ten, ten. Okay. SPEAKER 1 My hair will. Oh, no. No, no. I. SPEAKER 2 Really like when we discuss cases. SPEAKER 0 Oh, good. Good. Well, you know and and let's honestly, you know, you guys are much. Thank you very much. Sorry. No, no. It's good. No, no, I want that, I need it. SPEAKER 1 No, that's that's good. Because that's. SPEAKER 2 I could. SPEAKER 1 Have. No, no. SPEAKER 0 That's that's good though. That's, that's that's why we look at it and. SPEAKER 1 That's. SPEAKER 0 As I said, that's how you, how. SPEAKER 1 Everyone in the room. SPEAKER 0 Learn something because you learn, you know, you learn from your. SPEAKER 1 Colleagues because. SPEAKER 2 You were asking for the most, uh, the least invasive. SPEAKER 1 I know. And you're going. SPEAKER 2 Like. Like your assistant. SPEAKER 1 Like, exactly. I can't no, I can't do that. No, that's that's it. SPEAKER 0 That's perfect. But better to talk about it. And and the truth is, even though, uh, for good or bad, a lot of times I look at people like that and I'll be like, I don't think there's an ortho solution, but, you know, if she wants to go talk to an orthodontist. Yeah, yeah. Why? Why not? Oh, you dropped a sorry. Why not? Yes. Because you know what? SPEAKER 1 Yeah. SPEAKER 0 If somebody wouldn't. SPEAKER 2 Her. And yet. SPEAKER 1 It's. SPEAKER 0 Is it waste time? Maybe. Maybe not. But again, she's an engineer. She wants to really get through it, so. All right. It's going to be picky. SPEAKER 2 She wanted. SPEAKER 1 To hear. Hear from. SPEAKER 2 Yeah. SPEAKER 0 You had to hear from the orthodontist. SPEAKER 2 Yes, I needed that. SPEAKER 0 Yeah. SPEAKER 1 So that's good. SPEAKER 2 Thank you. SPEAKER 1 So maybe you. SPEAKER 0 Never know, but but I was just saying it's, you know, for for your, for, you know, your group, you guys have a lot of experience, a lot of knowledge. So it's fun to look at these things and kind of say, you know, what are we talking about? How do we think about things, you know. SPEAKER 2 But I was talking to her when you made that comment. I was like, what? Your result? I thought it was more natural looking because the incisal. Well, I. SPEAKER 0 Like the incisal edge a little. SPEAKER 2 Like that. You didn't touch it. And in my opinion, it look more natural than your approach. Yeah, but again, it depends on what the patient wanted. But the thing that I said is because before we, we, we even took that because we had a more, a bigger problem. Yeah. Now that the laterals. SPEAKER 1 Well now you turn it. SPEAKER 0 Into a different problem. SPEAKER 2 So now you start looking other things. SPEAKER 1 Yeah. Well that's. SPEAKER 0 That's one of the things that's so challenging about anything in the esthetic zone with patients. So you have people who go, you know, somebody goes their whole life. SPEAKER 1 Is. SPEAKER 0 Either crowded discoloration and all of a sudden they show up in their, you know, six years old and they're like, I want to look better. You're like. Start doing stuff. And like you say, you do a little something like you say, all right, what's the least you know? How about this idea? And like, oh, I like it. But all of a sudden they're spending. Now it's in their head. They're spending every minute of their life looking at their teeth. SPEAKER 1 And. SPEAKER 0 And, you know, they drive themselves crazy. They make you crazy, too. Um, one thing I say to patients all the time, all the time, which I hope they listen, you know, your hand patient, a mirror, whatever you do. Ortho. And they take the mirror and they go. And you're looking at it going, you know. Give me the mirror and you stand right. And so you take the mirror and you say, alright, for what it's worth. And I said, you know, sure, it's good to look at your teeth, but let me be honest, you know, nobody sees you. So look. And so you stand a couple feet away and you hold the mirror and say, now what do you see? Because I try to get them to think. The only thing that really matters is what does the world see and what they see from here. No one sees, um, but what they see from a couple feet, that's what everyone sees. And if it looks wrong from a couple feet, we've got to make it different. Yeah, but if it looks you, you go, oh, no, that looks great. Now then it's like, well that's you know, that's the solution. Yeah. Um, but it's, it's hard what I say to them sometimes, which sounds terrible, but I find it funny. Um, I tell them, I tell them that, you know. They like. No offense, but nobody in your life. That maybe your mother ever looked at you with the same. SPEAKER 1 Oh, nobody. Except maybe your mother. Yeah, yeah. That's true. SPEAKER 0 So. And I said, I'm pretty sure your father didn't you? SPEAKER 1 Maybe.