hello everybody I hope you're in a safe and comfortable place listening to this lecture I'm very excited to share with you a few things that I do in my everyday practice I will be focused on anterior direct composite Restorations this is definitely a passion of mine I do a lot of anterior bondings in my everyday practice and the goal today is really give you a little bit of sneak of how I do it in my everyday practice so that it can become a lot more predictable my background is deeply in biomaterial and dental material research this really started when I joined Dr Pascal mania's research lab at USC we went really deep into studying a lot of material bond strength bonding agents Composites and that's where I was heavily really exposed to what we call today biomimetic dentistry and after many Publications and graduating School the number of people who I call my mentors increased um and this is who I consider my dental family today and I would not be here giving you this lecture if it wasn't for their continuous support very excited that together with Dr manye and Sam alawi and Michelle Monier we were able to create something called crbrd Center of Education and Research in biomimetic restorative Dentistry it's an educational platform where we hold Hands-On courses here at Beverly Hills Dental Lab so the way we look at the anterior direct composite Restorations has really changed over time I've personally practiced a lot and the quality of the Restorations really come down into how much time we put into it and how much practice we do it and it's really important that we start to shift the way we think about composite Restorations if this is something that you want to incorporate your everyday practice um I have prepared a little list for everyone here it's sort of a checklist of what I go through personally for every case where we are indicating direct bonded additive Restorations to do a smile makeover and by the end of this lecture I hope that everyone has a little bit of feel of everything that you see on this page um of course in 50 minutes we can't go really deep into every single topic but I've really tried my best to compact everything so you get a sense of the workflow I take my patients through every time we want to do direct bonding as an alternative to other aesthetic treatments like veneers and of course it starts by Design if you look at composite Restorations at long lasting aesthetic treatment you put just as time and passion in the design portion of your treatment um as you do with veneers and it's really important that you take this step very seriously when someone like this walks into your office and there are only 21. at least for me as someone who really appreciates preventative and minimally invasive Dentistry I want to push my boundaries and try to offer more than just shaving these teeth and putting veneers on there I want to push my boundaries and say maybe I can do bondings here and even if that buys my patient 10 15 years of happiness and then they do veneers in 15 years I have one and that's enough for me to really save this patient from going through any invasive procedure so early on in their life going back to the design the first thing we do here is of course a diagnostic Workshop we want to understand where the tissue is what are the possibilities and in most additive cases when a wax up is done my all-time favorite way to really make sure I'm on the same page with the patient is a diagnostic mock-up as you can see I make a few putty matrices just like we do for our linear cases understand that I don't need to reduce anything and as you can see the wax up has been done completely additively here and I simply make some powders with pmma material I press that onto the patient I paint the provisionals sometimes I have a little bit too much fun with painting these and I just let the patient live with these for a few weeks to make sure that this is what they want and if there is any need for aesthetic crown lengthening or manipulation of the tissue before me will move on to our bonding steps but something that's been replacing this step more and more for me recently is doing a digital design for my patients before we even think about the wax up and I have realized that recently this has gone a long way what I what do I mean by Photoshop Smile Design or simply doing a digital simulation of what I have on mine for my patients for example this is a wonderful patient that just wants to make some improvements with the bonding but in in my head when I sit down and I look at this picture I understand that there is more than just bondings to do if I really want to change this patient's smile I need to First fix the environment and this is a perfect case for an aesthetic crown lengthening and balancing the pink per se before we move forward with the bonding so here what I'm doing I'm using some really simple Tools in Photoshop just so I can create a very realistic view of what can be done for this patient if they go through aesthetic crown lengthening and bonding and essentially this is sent to my patient as a digital stimulation of what I have in mind for them for their smile together with the specialist when they can see what we are thinking in a visual way it puts me on the same exact page with the patient and with the specialist they understand what we're trying to do and it's a lot more than just a black and white paper that we call treatment plan so I've been doing this more and more and I've realized as I'm doing more of these digital analysis of my patients I just learn a lot more about their face and every thing that will be the environment of my bondings if the environment is not ideal the bondings will never be ideal and let's take this case as an example I'm studying this patient now for most of my patients I just take a high quality photograph before we start any aesthetic treatment and this becomes a chance for me to really sit down and study exactly what's going on with the lip what's going on with the midline length of centrals and I idealize that again using tools like Photoshop and keynote and I send this to my patient and if this is something that sounds good to them it becomes a really nice and enjoyable conversation between us to say that listen I can't just do a composite restoration for you here if you want to do this we maybe want to need to fix the lip we may need to do a little bit of aesthetic crown lengthening and this simple digital design puts everyone on the same page whoever is working on the lip the periodontist that's going to be working on them as far as the aesthetic ground lengthening and this digital Smile Design done simply with Photoshop and keynote has really become the design engine for most of my cases and my patients love that once we are past the design portion of our aesthetic makeover we have to keep in mind everything that needs to be done before we do any bondings and this list that mostly has to do with bleaching and resin infiltration and balancing the pink is what I'm talking about here um let's talk about bleaching you always want to make sure that you get the bleaching out of the way before you do any bondings for your patients it's really important to educate them that if they do any bleaching after bondings are done and the color of the bondings will not change but the color of the teeth will change um to this date my favorite way to do bleaching is at home bleaching with custom trays I like to use really low percentage caramine peroxide we asked them to use it one to three hours a day depending on the tolerance and they do that for about three weeks and we can see a significant difference if they actually do it every day and follow your instructions so on this patient for example we get the bleaching out of the way and they came to me asking for me to fix this white spot on their teeth with a composite veneer direct composite and just thinking about my list and going through everything I need to get out of the way before we do the bonding the first things that's come to my mind is bleaching and of course when I see a white spot like this today I do not want to drill it and do a composite restoration I want to use all my tools and be as many Mullally invasive as possible and that's why I have resin infiltration in my toolbox all the time this is another young patient and this white lesion is really bothering them and it is even more noticeable now after they did the bleaching so I wait a little bit two weeks after the bleaching is done for everything to stabilize my favorite system for resin infiltration is the icon system from DMG all I need to do here is to do a simple isolation with rubber Dam and I go through my steps with this special etch system that comes with the resin infiltration for the anterior teeth and we basically open the pores of this white lesion and all we are doing but infiltrating resin is changing the refraction index of this white lesion this is immediately after resin infiltration this is also a polarized picture of the same patient after resin infiltration is done and all I did after is to add a very tiny incisal Edge only enamel shade just to complete that little fractured part that he had and I was bothering him on tooth number eight so here I was able to really achieve something that made my patient really happy but simply resin infiltration and bleaching going along in the word of bleaching we also think about internal bleaching so as you saw on our list of everything we need to do before bonding another type of bleaching was internal bleaching and I would like everyone to think about this option also before you do any composite Restorations for example let's take this patient as someone that we're interested to maybe be very minimally invasive and push our boundaries and try to match tooth number nine here by composite Restorations of course because of the core color if that's something you're interested in we have to shave the tooth but this tooth has a root canal and any time I have an existing root canal and there is color discrepancy I think about internal bleaching here I performed the walking bleach technique with sodium perforate um I mix it with dental anesthetics you can look up this procedure it's really simple to do it and you need to carefully access the existing root canal and bury this bleach with the barrier between your bleaching space and the get the percha and you redo this process once a week for two three times and the results you can get from internal bleaching is very very fascinating and it is very important that if you ever consider doing internal bleaching you do put a barrier between the beginning of the good aperture and the space that you've left to bury your bleaching material we can see the kind of difference we can get with internal bleaching it's it's fascinating to me and now for this patient you can start to talk about bonding because you fix the environment you fix the core colors and that is essentially what will allow you to do now additive treatment for your patients um balancing the pink is another thing we also talked about this is the concept of doing any aesthetic crown lengthening needed before any of your bondings always analyze the gum line and understand if there is a need for aesthetic crown lengthening before you jump into doing any direct bondings for your patients if you need to do any aesthetic ground lengthening um the wax up portion of your design can always be what guides the periodontist and the surgeon to perform the aesthetic ground lengthening and put the pink where where you would like or where you have in mind the digital smile simulation is also a very helpful tool for periodontist to understand what you're trying to achieve and help them to really put the pink where you need them to put it based on the visualization the digital visualization that you have for your patients so in summary all these procedures any kind of bleaching whether at home or internal bleaching or resin infiltration or balancing the pink these are the things you have to think about before you consider bondings and you have to think about this as the environment of the bondings and the better the environment of your bonding is the better the end result will be once the design and the pre-bonding steps are done then we are ready to think about the shade I want to just tell you a few things about the shade that's really important that I've learned over time that is something that I consider for all my direct bonding cases in the anterior region Whenever there is a patient it's a young kid that just walks to my office it's a broken Central I get a lot of these treatments um I love treating these with anterior bonding and I'll show you how simple and easy this workflow can be the first thing you need to do is to take a shape and that is simply because of this phenomenon of tooth dehydration dehydration is real and it happens really fast I really like this study because it measures the lab of natural extracted teeth while they are dehydrated for up to four hours and we can see that the difference in Luminosity is significant when teeth are dehydrated by simply patients keeping their mouth open or just talking for too long even by putting an object the way you perceive the shade is completely different and doing cross-polarized photography is also another way for you to understand the true shade of the patients and what you're dealing with these two concepts are very important in shape making sure you take your shades when everything's completely hydrated and using a polar filter on your camera to really take away all the shine and understand how the true color of the T3 relates to any shade guide that you're using so this is the same case uh that we showed this is a broken tooth what I do in this case is that I first make sure that there is no need for any endotonic treatment everything tests normal I don't do um any bonding in this session I simply just seal the area only if my patient is sensitive and I take a quick shade and later on I will show you what I do between the time where this patient goes home and they come back for the bonding that I need to do so it is very important that you keep dehydration polarized and the wet mock-up in your minds when it comes to the shape we will get to the wet mock-up soon it's a very simple step that I've added before I do any anterior bondings just to make sure that the shade and the combination of the layers you have in mind is something that will actually give you the results you're thinking isolation for me is a must I do that for 99 of my cases when I'm doing direct anterior bonding um it really goes beyond why isolation was initially invented and I love showing these electron micrographs um that I found from this fantastic team in Japan when what they did they basically make these slabs that we do make when we do micro tensile bond strength test every time you want to do a test of bonding we basically cut a tooth into in half where we have exposure to both the Dentin and enamel we do whatever bonding procedure we're trying to test and we stack composite on top then we basically cut these slabs into one by one millimeter rods and we glue them into a machine that pulls that both parts of this slab until they demand and that essentially gives us a number that helps us understand the bond strength so this team used the same slabs and looked at the bond in interferes between the Dentin and the composite and bonding agent and they looked at it again while responding was done in a situation where the teeth were exposed to minimal hydration or what we can call water contamination and just by looking at this interface and comparing it to what it can look like when the area is completely dry and isolated is completely convincing enough for me to start using rubber down Rotterdam isolation when it comes to these kinds of additive procedure is more than just your bond strength the patients are more comfortable I have unlimited working time and I can take my time and layer my composite in the working environment is a lot cleaner and access is a lot more important than anything for me here other than the bonding advantages because if I don't have this axis that you can see I've created with floss ligation it is extremely difficult for me to really blend a thin layer of enamel which is my final layer that gets really close to the tissue line and goes slightly under the tissue and polish it and make it seamless so I avoid any type of gingival inflammation if you do decide to incorporate rubber Dam isolation in your everyday practice go all the way in don't just put a rubber Dam in take your time do do the ligation and use high magnification to check that the rubber Dam that you're using actually is working and there's no points of leakage this is a rubber Dam that I highly recommend for any dentist that are new to this world of isolation and they want to get started it's really easy to work with and it just makes working with Composites and um your material a lot easier start slow maybe do a few cases um every week and then slowly you'll see how it can completely change the way you do Dentistry now when it comes to anterior Restorations um the way I isolate is very simple I almost always use double zero clamps these are my anchor clamps that just hold the rubber Dam on the premolars as you can see I haven't put rubber Dam holes on the premolar areas and this will avoid the need for local anesthesia just because the rubber dam is really working like a cushion between your clamps and the areas where you're placing them you will see for all my cases I just use double zero and floss ligation is what gives me that access that I was talking about just notice the difference of how much to structure I have access to after this ligation if I really need to like it my case is what you see on the top is actually the bottom of my rubber band frame I can place the rubber Dam frame inverted and attach the floss ligation to my rubber dab frame and pull that manually so I can really blend my composite where I need to and close diastema I usually use this when I'm dealing with really deep black triangle closures and this access is everything once you go through your isolation you use the rubber now you do your floss ligation and everything is set you can then think about cleaning the teeth before you start the bonding protocol what do I mean by cleaning one of my favorite devices to this date when it comes to any bonding is the aqua care you don't need to necessarily use the aqua care I happen to like this machine because it really mixes the air abrasion process with water and that's a lot less messy than just using a regular air abrasion units however that's not the point I uh basically use 29 Micron sand you can use any air abrasion system and this is just a difference of a microscopic surface that you work with before and after her abrasion and when you isolate um and you have access to this sub gingival areas most of the time if you look at the tooth surface under microscope you find a lot of plaque and feel that can get in the way of your bonding and this plaque is something you can easily take away by air abrasion besides that uh it of course increases your bond strength by creating microscopic micro mechanical retention so I highly recommend this step before we do any bondings for our patients if you don't have access to air abrasion and you simply want to clean the surface also using pumice is a great way to do it you can just wet a cotton ball and put it in the promise and scrub the teeth heavily so you get rid of any existing film that could interfere with your bonding surface for your anterior cases now after all these steps we get to bonding and I want to talk a little bit about the basics of what we need to keep in mind when we're doing bondings especially in the anterior region and this is something I cover a lot in our Hands-On courses for the posterior direct restoration and that is simply regardless of what bonding systems you're using is the areas of bonding that you need to focus on before anything your Edge area needs to always be the biggest area of your bonding surface you need to always go beyond the Border Lines of where you're planning to do your composite restoration I'm sure you've seen these brown spots a lot when you're doing exams for your patients and what these essentially are is the composite bonded to an unetched surface when you have a surface that's on etched over time it is exposed to micro leakage from all the liquids that go in the oral environment and that area that you see is brown that's above the composite it's simply discolored because of these micro leakages SIM and this could have been avoided if during the bonding The Edge surface was extended higher up Beyond where we were planning to put our composite there is no such thing as over etching you can never over Edge always feel Brave to etch beyond your bonding surfaces and then that gives you the right environment to apply your primary if you're using a three-step bonding just apply your primer into the denting as you can see and the most important part which is the application of bonding goes on all the surfaces of your restoration but always keep in mind that it needs to be kept short of your Edge area I apologize for having such a dry throat I'm trying to drink a lot of water I've had a long day of patient care just bear with me thank you so much so this is an anterior case where we can simulate these bonding areas as we just looked at on a posterior tooth this patient walks into my office and he basically wants to change this composite that's discolored on his front tooth and try to match a tooth Number Nine by doing composite Restorations on eight and he would also like his right lateral to be improved when I'm ready to do my bonding after I do my isolation and I clean the surface with air abrasion um I think exactly the same way as we explained on that posterior tooth for most of my full surface anterior bondings I etch everything and absolutely everything you have nothing to lose here it's so much better to have a maximum area Edge than having those brown lesions later on around your composite Restorations then I add the primer only in the areas where I have my Dentin and of course the bonding goes everywhere and that gives me a really nice clean area to perform my bonding and after polishing now I can see that because of isolation and the etching and the surfaces that I was able to have access to I can have really predictable results simply by additive Dentistry and this patient everywhere they went um the one of the only treatments they offered was ceramic veneers and to me it's very difficult for a lab technician to match everything by just doing two ceramic veneers on seven and eight and um with today's composite material it's fairly easy to match such Restorations and we're going to talk about how I do that after the bondings it's really important to have a little deep understanding of uh tooth anatomy and the layers and the thickness and the shape of the teeth when you're dealing with anterior bondings and you're offering that to your patients as a aesthetic option and I I want to really encourage all of you to take some time later on and read this paper this is a beautiful paper by Panos bazos and Pascal Mania where they really break down the micro Anatomy of all anterior teeth and these are really important um facts about the nature of teeth to keep in mind it's really important to know that for example the thickness of the enamel on the cervical lesion is really between 0.2 to 0.4 millimeters and when you're lower down towards the incisal edge this thickness of your enamel layer increases and this article does a wonderful job showing you what happens to the thickness of Dentin and enamel as you go from the incisal all the way to the gingival end of all anterior teeth this article really helped me to understand why when we change the thickness of your enamel and dent in the air is really the way your composite Restorations look uh can improve and be different the way I do my anterior Composites is very simple I don't really mix 30 layers of composite I keep these thicknesses in mind I usually have a very opaque layer of Dentin in the back if I have incisal fractures to mask the area in the back I put some internal characterization and staining in the middle to mimic the white spots and translucency and if they have really warm spots on the Dentin I do all of that with resin colorants in between my opaque Dentin layer and the final layer really is the enamel layer that goes on top all of the composite Restorations that you will see in this presentation has been done with this technique and that takes me to the importance of doing the diagnostic wax up yourself it's really important for any dentists that are thinking to do more and more anterior additive direct composite Restorations to as something they would like to offer to do the wax up yourself do not send these wax up to the laboratory this is your very first chance to try and understand the amount of material you're allowed to put on these teeth to do a diastema closure for example in this case and once you do the wax up you will see that the way you place your Composites are different because you know exactly how much composite you're allowed to put on these teeth in which our areas you need to put a little bit more in which areas you have only a chance to put a thin layer of enamel and these are things that you need to experience with your hand and once you do the wax up the way you do your Composites will be completely different now one of my favorite systems now on the market to do a direct anterior bonding is the genial Accord system from GC there is a many reasons why and this is my material of choice today when I'm doing anterior composite and one of them is compatibility I really need any material that I'm doing anterior composite bondings with two have the ability of changing to a friendly viscosity when they're put in my composite warmer we need the um composite to be very moldable so that it can go to this tiny diastema areas especially when I'm trying to close black triangles and this composite really changes to a friendly viscosity when it's manipulated or mixed with your bonding agent or when it's placed in a composite heater radio opacity is also very important for me I take follow-up x-rays especially when we do deeper Composites to close black triangles just to make sure that we don't have any sub-gingival excess and this material has great radio opacity very resistance is very important this is something that I've seen a lot of companies struggle with of of course we want a stronger composite and for that to happen we require a higher filler content in the composite now you see what you see with a lot of Composites is that when the filler component goes higher um the polishability comes down and another reason why I like this system is that they have really found this perfect balance of the amount of fillers they put in it so it's really nicely wear resistance but also it has amazing polishability especially with their enamel shapes and the shade options are also another reason why this composite is perfect for anyone who wants to start doing anterior Composites we have two enamel Shades most of the time at least in all the cases that you're seeing in this presentation I use the je as my enamel Shades that stands for junior enamel it's a very natural opalescence enamel that makes your Restorations extremely natural and as you can see you can achieve a variety of shapes with only five simple core shades you don't have to go Advanced and start layering to achieve really good results and I want to show you but also they do have all the rest of the opaque Shades available if that's something you would like to do this is a step that I highly recommend any dentists that are not familiar with a composite system to take and it's a device that you can simply purchase from smile line and it's called My shade guide what is this device it's a really simple way for you to create your own combination of Dentin and enamel with the composite Restorations that you have it comes with really simple instructions and with modes that will allow you to press the same amount of Dentin and enamel into form of a shade guide with as many combinations as you like let's go back to the first case we talked about when it came to the concept of shade selection and the reason why I didn't do this treatment immediately is because I was in familiar and comfortable with the composite system I was using at the time I do a polarized photography my patient was comfortable they were not in pain and I just asked them to give me a day to understand what Shades I'm going to use I take these pictures and when they're gone I combine all the different denting and enamel Shades that I feel could match their remaining to structure the best and it's as simple as writing what Shades you mixed and bringing those Shades and taking more photos before you do your procedure if you remember we talked about the wet mock-up under the shade selection tab which is something extremely important for me what is a wet mock-up it's basically you taking the potty matrices that you made from your wax up and quickly doing your composite restoration [Music] um this should happen under five minutes um you don't need to worry about the shape you just stack on your enamel layer and the denting layer if you want to really make sure you're getting it right do all the characterizations that you want to do also in the middle and do all of this without any etching and any bonding agents and without rubber damage isolation this is gonna come off easily you can just put a little pressure on this piece and comes up but the reason I do this wet mock-up is because it's my way to make sure that the Composites I'm mixing to create this tooth structure for this patient is very close to what I want to achieve and sometimes even after I do the wet mock-up I ask the patient to close their mouth and rehydrate for 10 minutes and I look at my wet mock-up and if what I see is desirable then with the peace of mind I put my rubber Dam here we just follow the same exact steps we talked about in this lecture do my rubber Dam I like to put Teflon on the adjacent teeth especially when I'm etching and applying my bonding agent just so that it doesn't carry over to the rest of the teeth you can see how the ligation is helping me here and I perform now the same composite using my putty matrices and the same exact layers that I used in our mock-up and it can go a long way and just because I did my homework I did a quick wax up and I did my shade selection the way we just talked about it just guarantees that you can get a final result that is predictable I rather take much longer at the beginning than the patient really go through me having to redo their composite restoration and if it's done and it doesn't match let's look at another case that we got a few picks from that really summarizes all these steps that I've been trying to talk about in that checklist that we presented at the beginning so I follow up the first favorite way for me to show the patient what I have in mind is a digital simulation of what I would like to create I want to see if they like the shape of the teeth that I have in mind so this is simply done by a Photoshop and quickly morphing the teeth and she loved it and this is now what's going to run and Inspire my wax off I complete the wax up the wax up is done I make my putty matrices and that takes me to my wet mocha after you work with a composite system for a while then you get really comfortable with what kinds of shade you would like like to pick you don't necessarily need to use this my line system to pre-make the shades that you think will give your patients their desired shape here I'm using the Accord system again and I'm using two layers I'm planning to do a little bit of characterization for white spots and blue but this is what my wet mock-up looks like I simply put a01 in the back and I put some J on the top I take a photo I like what I see I'm confident now to put my isolation on without worrying about shape remember what I talked about the isolation it's really the access part that allows me to create triangles and create line angles that can make my final composite seamless and this is why I like doing isolation and of course again it goes beyond all the other advantages that rubber Dam isolation has I simply put the lingual potty Matrix that's made out of the same wax off that I did myself just so I get an idea of how much length I'm adding I do clean everything before I Bond these teeth I'm using aqua care here you can use pumice or any air abrasion system that you like and I perform my bonding one at a time here I finish number eight with a01 and j e only um I finish the contact point with the soft list disc and now I can only focus on the adjacent tooth I put a Teflon and this are the kind of cases where the genial the court system and the friendliness in the flexibility and viscosity of the material really allows you to push your Dentin shade in that tiny little space so you can get your opaque Dentin in the back do some characterization in the middle and finish it with your enamel shape when you're finishing and polishing your Composites taking photographs are extreme extremely important and these are two slides that we always show in our photography boot camp just so I can show everybody what different representation of teeth you get when you're using different flash system and this is a photo that I took from one of my patients using a ring Flash and this is the same photo using a dual flash and this is the kind of flash system that really allows me to evaluate my line angles after I do any direct bonding so the finishing and polishing process is a constant back and forth between taking photos and using Diamond burs and whatever polishing system that you need to use whatever works best in your hand to really slowly add texture and change shape to what you would consider closest to what the digital design explained to the patient and of course your wax up it's important to realize that the finishing process doesn't necessarily need to be done in the same appointment it's very common for me to do a rough polishing send my patients home and ask them to come back after a week for me to basically look at it again with the fresh mind and finish everything add texture take photos understand what line angles I need to correct I use soft list discs a lot you don't need to go into the detail it really is as simple as taking these photographs and understanding what you're missing between your Composites and your wax up and carefully reshaping them so you get something that is desirable remember this case at the beginning and I wanna walk you through what happened with this case so as you can see on the right side now the gum is completely balanced the lip is balanced just that digital design I did at the beginning for her was convincing enough for her to go and balance the lip on the right side and she went through aesthetic ground lengthening to lift up the pink on the right side of the face so then after we did a little bit of bleaching so we've done all those steps that we talked about that we consider pre-bonding steps so here I wanted to do a wet mock-up but I was a little disappointed because this tooth in the background it was very dark what do I find on the lingual of this tooth that we had a very large discolored old composite that was affecting the color of this entire tooth so when you have cases like this that are challenging as far as color do not rush the case here for example I just hold back and I say you know what I'm going to remove this lingual composite and change it and let the patient rehydrate and do the rest of it on another appointment I go to the other tooth however and I add only my enamel shade I use j e again here on for this case and I complete my line angles but I leave the facial aspect of the discolor tooth for another session here you can see that I have a very nicely shaped je layer only on one Central and so I said this is the other Central that was discolored however when she comes back we can see that the color of the tooth is completely different now I have the confidence to do a wet mock-up and choose my colors correctly I do my wet mock-up I use two shades I do a little bit of internal characterization in between and I finish the line angles and the facial aspect of this tooth exactly based on the neighbor tooth which we completed last time and we can see after rehydration we can get really predictable results and think about this case this patient went and listened to us trusted us went through aesthetic crown lengthening through bleaching they fix their lip they fix the environment for you I cannot fail them now with my direct composite and this is a really good example of where you need to take take things slower and take a step back do your wet mock-up if there is anything in your environment that gives you doubt and makes you feel like the color may make this a tricky case for you just take a step back just like I did in this case change the environment idealize their environment and doing all these steps and educating your patient while you're taking it slow is really the core of what can give you a results like this don't just think about composite as another composite restoration think about it as a definitive restoration do all this studying that we mentioned before you do these composite restoration and that workflow has been really what has allowed me to be able to give my patients the these Restorations with this quality and um these steps really has helped me to not only achieve long lasting Restorations but also Restorations that do not come off just as composite Restorations I wanted to apologize for my voice before I jump into q a I had to drink a lot of water I had a dry throat and my sincere apologies for that but I really hope that through this presentation we were able to really have and create a workflow that if you follow it can guarantee and give you that assurance that you can create Restorations that could be as long lasting and as aesthetic as ceramic Restorations please feel free to email me in the future if you had any questions I'm going to now open up the Q a and read some of your questions and answer them so uh we have a question that says have you ever considered the one-shaped systems uh I have not the one-shaped systems are Universal Composites um and they are incredible and it's simply because of the change of the particle shape in their composites instead of using these crazy shapes of fillers and glass they use really round shaped Composites and when the components of your Composites that they're using around and it basically gets this camouflage effect that wherever you you put them they kind of blend in as far as the color I do not like to use these systems for the anterior um restoration especially the type of restorations that we reviewed in this short presentations and I found it difficult for me to really achieve the the quality of the Restorations as far as color and characterizations with the one shade however it's a really good way to um the basically tackle posterior Restorations if you're not a big fan of mixing Composites and different colors um we have another question and that says is this covered by insurance this is a very very good questions most of these procedures are not covered by Insurance unless you're in a situation where you're dealing with severe Decay and that takes us to a discussion that could become a very long discussion that to be a provider that can provide this and survive as a dentist you need to move towards a fee for service system um if you're an insurance office it wouldn't make sense for you to sit down for one hour and a half and do this kind of isolation and layer do your wet mock-up and wait for the patient to rehydrate you like your color you take photos you isolate and you finish and you bring them back again to add texture on another appointment this does not work for insurance based offices because most of these Restorations are considered aesthetic treatment and they're not covered by insurances with the fee for service you just make a disclaimer at the beginning to all your patients and you explain that they are responsible for the full amount um of these Restorations and um I know we're going to have a podcast about this lecture a few weeks from now and I think this is an amazing topic to talk about how do we charge for these Restorations how do we charge our patients and how do we explain these charges to them so that we can survive as dentists and do this kind of time consuming Dentistry so uh Lucy asked could you please give me more detailed techniques for floss ligation I always have trouble to stabilize the floss into the socket thank you absolutely so the floss ligation there's two types of floss ligation there is simple fossil ligation and there's double floss ligation and I would be happy to show any of you if you're ever here for our courses or you simply want to visit me here at our office you can find videos also on YouTube the ligation is not the issue the the issue is that once you put the ligation around the tooth lingually you need to use an instrument and make sure that you keep this ligation under the singular for the anterior teeth once an instrument is holding this ligation under the cingulum then you tie your floss facially and this is what allows this floss to really go to the core of the tooth underneath the rubber Dam and keep the rubber Dam in place for you um as you saw on one of our first slides I also like the technique of tying these flies to your rubber Dam frames and using an inverted rubber Dam to constantly push up this ligation that's for having extreme access for cases where you're trying to close black triangles or you're doing a diastema closure um take it slow do the ligation slow take your time rubber Dam and location is something that needs a lot of practice but when you're doing it if you work under high magnification and if you work with a slow speed you'll get the hang of it very easily um Dr Ali asks did you mix and match different brands of composite best brand for pink composite for cervical abrasion with recession according to you I was using Shofu what do you suggest yes I used to mix and match different brands of Composites but over time I learned and I really wanted to simplify my life and that's why my favorite system now is the genial Accord system because it has few Shades and the few enamel Shades that it has really has the translucency and the opalescence of the natural look that you saw we were able to achieve in our Restorations now I don't mix and match anymore I try to have a simple way of doing the Composites and just to go back to that slide where I broke down the type of layering I do my favorite way is a very simple three-step way to do it I do a lingual shell depending on what kind of anterior Composites you're doing your lingual opacity will be different in between this lingual share and the enamel shape I use resin colorants there's many different resin coloring kits on the market GC has an amazing one that has all the different types of colors that you're allowed to put in between your composite layers and that's what I play with a lot if I wanna add a little bit of pink or warm to the gingival if I'm doing an extreme big anterior composite restoration I simply mix a little bit of brown and Hazel and white and I create the color that I like I put it in between my Dentin and enamel shade and then I cover all these colorants with the final enamel layer and usually with this three-step technique I am able to get predictable results this was a 50-minute presentation I of course couldn't really go too deep into the layering concept there is so much I wanted to talk about uh but these three layers really um is the way I do all the Restorations that you saw in my presentations um just a palatal opaque um Dentin shade and characterization enamel shade I highly encourage you to start doing the wet mock-up if you have a complex case bring your patient in and let them know that I really want to make this composite great I'm just gonna try to do it without using any rubber Dam and bonding and just leave it on the tooth and see if the colorants and the mix of Composites that I'm planning to use would really give us the result and the patients would love that and if you're charging the correct fee for all these Restorations all this extra time that you put in to doing them and will make sense uh another [Music] um question here is how much did you charge for that number eight on the kid um really in reality I don't like to talk about the pricing because that's uh what you know something that's irrelevant but let me just answer it just so you get an idea and for that composite I believe we charge somewhere between 800 to a thousand um and again I would love to talk about this more and more uh in in the podcast that's coming up because it's not about making money here it's about making sense of everything you're doing to make that composite restoration a restoration that is not only long lasting but matches well gains your patients confidence back and the way we do it as you saw is time consuming most of these appointments are above one hour sometimes on that diastemical closure that you saw where we just did eight and nine that's a two and a half hour appointment because you need to add up everything you do to taking a picture taking a shade you need to charge correctly and you need to educate your patient while you're charging higher than their expectation it's because of the work you're doing it's because of the quality of your work and all these steps that we learned through this presentation takes time just putting on a rubber Dam takes a lot of time and if they understand your philosophy they would be happy to pay for that and I've realized over the past few years there where I've changed my practice to a fee for service setting the type of patients that come to me change I barely have patients that have Financial issues I get patients that are educated because of internal marketing and the patients that my patients bring for me and they come to me for the quality of the work because they understand that with the amount of time that they put with the rubber Dam and with the the initial design that we did all these things add up and they love that and it really changes the types of patients that walk into your practice on a daily basis and that's how I really explain our fee for service environment and I know this is a very we can just have a lecture on that how to charge for these how to tell your patients why I'm charging this amount and um I would be happy to really just talk about that in the future um because if you're doing this kind of Dentistry but you're not surviving and you're not financially happy as a dentist it doesn't make any sense you will not survive and you cannot do it you have to make sense and that's essentially what defines your charges not the insurance or anything else I think that's about it um I wanted to really thank everyone for listening to this short lecture um think about that checklist uh I hope you took a photo of it think about all those steps I know it's a lot of steps but think about it and do them and go through them every time you have a case where you want to do anterior bonding um and feel free to reach out to me via email or Instagram I'm always available to answer any questions that you like and once again I wanted to apologize for my voice I lost my voice at the beginning but I really tried my best to carry on and finish this presentation by drinking a lot of water I appreciate all of you and I hope that we can personally meet sometime in the future have a wonderful rest of your day