00:00:00: In this podcast I talk with Roberto from Italy.

00:00:03: About the limits of direct Restorations when we should go for an indirect restoration.

00:00:10: Since this podcast is all about looting we talked about luting indirect composites.

00:00:17: Hybrid Ceramics Ceramics and even fiber posts this podcast is part of the G someone Symposium in preparation of the 100th birthday of cgc cooperation have fun listening.

00:00:30: Music.

00:00:40: Welcome to Today's Show I'm connected to Eataly with Roberto welcome Robbie at of I George 9th nice to be here with you today thank you very much for this kind of mutation.

00:00:51: Who actually be going to talk today about looting and indirect Restorations so the question which comes to mind where do you start where does your direct investigation end and where do you start with your indication for indirect Restorations.

00:01:06: Yes well the topic is pretty why it is pretty controversial for sure because you know that are

00:01:14: dentists more skilled with direct composite Restorations and others that prefer indirect for

00:01:20: many different reasons I'm mainly a prosthodontist I I've been working at the University in the division of prosthodontics for more than 20 years so you can imagine that my.

00:01:31: But ground is mainly indirect okay

00:01:34: anyway nowadays compositor for sure very smart materials very interesting boat for

00:01:42: mechanics biomechanics and Aesthetics so according to me maybe that the dimension first of all of the cavity to be filled.

00:01:52: Secondly the number of restoration to be made and then

00:01:57: mainly to the most important parameter the occlusion can be the variables that can lead me towards a decision for a direct or indirect restoration,

00:02:07: for sure you have to also consider that the.

00:02:11: Average dentist as to take care of this time so maybe a direct restoration.

00:02:18: Is a One-Shot appointment but it's longer than an indirect restoration so it depends on the attitude and the skill of the dentist for sure

00:02:27: but I guess that according to my experience at the University with the undergraduate students for sure the dimension and the complexity of the restoration needs the first issue to be targeted for sure

00:02:39: actually it's kind of interesting I thought you would be saved for example the size of the contact Point that's usually like an.

00:02:47: Fight prosthodontics way of thinking.

00:02:51: I'm surprised that you didn't say that well as I told you before for sure it depends on the on the attitude and on the skill of the dentist I can give you my experience with indirect restoration and the contact areas because.

00:03:06: That's more than 15 years that I've been working with the cad cam systems and with the digital Technologies.

00:03:13: And the can tell you that if you work on your own I'm thinking about the designing of the restoration or if you refer to a dental technician.

00:03:21: You will have for sure very different outcomes according to the software you're using according to the material.

00:03:28: So in my opinion I've been working with a couple of dental technicians for many years

00:03:35: and for example when we started treating little a silicate and zls so

00:03:41: G of cornering fourth-leading filing eggs with the same offset parameter parameters of the software we had completely different results.

00:03:51: So the management of the contact area of board in direct and indirect restoration is.

00:03:59: Pretty complex according to me for sure you can imagine that the indirect management of contact areas.

00:04:08: For the average dentist starting safer if something simpler because you just have to refer to a good shaping of the designing of the restoration during the

00:04:19: the cat can face the cat face more or less Okay so.

00:04:23: I am according I agree with you when you say that the management of this topic is very very uncomfortable sometimes when we talk about direct restoration that's why firstly told you

00:04:37: the dimension of the cavity and the number of cavities you have to treat it very important because of course if you have just a first class

00:04:46: maybe you have no problems even if it's a pretty wide.

00:04:50: Why is if you have a second class or if you have several mod cavities to be managed in the same appointment Maybe.

00:04:56: It's very much more difficult for a direct restorative approach

00:05:01: I think when it comes to time every dentist understand that not every patient wants to come 10 times for,

00:05:08: a single illustration and even sometimes quadrant appointments are kind of a hassle.

00:05:14: Direct especially when it comes to occlusion yes definitely definitely I also think something if you are.

00:05:22: Talking about direct restoration with a very skilled

00:05:26: dentist maybe you can manage sixth interior direct veneers in a couple of hours.

00:05:33: YMCA if you have to treat if you have to deal with the dentist with no great attitude towards this kind of restriction may be the time becomes longer

00:05:43: so in my experience nowadays for sure approach to treatment requires at least three or four appointments but I can shorten them.

00:05:53: According to my current workflow.

00:05:56: For sure you know it's always a borderline topic this the one you chose for me today so it mainly depends on the expectations of the patient it depends only on its compliance because.

00:06:11: First of all we have to think that composite Restorations can be extremely natural tooth like in their appearance but they have to be

00:06:22: somehow controlled over time while more or less.

00:06:27: I see more or less because Ceramics have of course their margins their interfaces but usually the main aesthetic result is much more comfortable for the patient.

00:06:38: So it depends on so many different variables and we have not to forgot to forget that the cost of these Restorations can be.

00:06:48: Very very different although I can tell you that

00:06:51: and neatly in our Market in our Dental Market if you go to Top Notch restorative dentist you can pay as much as for an indirect restoration sometimes it depends on the target of the dentist and

00:07:04: the patient of course well you have some popular dentists for composite and Italy that was weird.

00:07:12: And one famous quote from vanina is well I can do a natural-looking central incisor it's going to cost you a thousand Euro.

00:07:20: I've had to redirect and just add something or indirect.

00:07:23: Cut something away yeah presents the say this was exactly my point what are you talking about Campo sides do you also have experience about indirect Composites and the posterior region.

00:07:37: Yes definitely I have because I started this kind of clinical pathway when I was a PhD student in Vienna with Professor Marco Ferrari.

00:07:46: Because at that time we were using materials just like writing direct and grab your call to make this kind of indirect Restorations.

00:07:54: For sure the performance according to me is Justin meat in between a direct and indirect.

00:08:01: Restorations for sure I can also tell you that it's about four years that we are.

00:08:07: Working at the University in Naples at the University Federico II where I'm actually teaching with my director Professor Fernando de noronha we working with the hybrid Ceramics and race in Nano ceramics.

00:08:21: So you know it's a very huge family of new Innovative and smart materials that are just in between.

00:08:29: Composite and ceramic according to our experience they are much more similar to composite than 2

00:08:37: Ceramics and I can tell you that the average performance in the medium term of course because I have data looking back at no more than 4 years of course there are really encouraging because,

00:08:50: the quality of the direct treatment of compositive according to me excellent you can take advantage and cementation using the same material to loot your indirect.

00:09:02: Composite restoration so you will have

00:09:05: just one adhesive interface instead of two and this could be a very interesting interesting point from a clinical viewpoint

00:09:13: and you have to consider as well that finishing and polishing of composite restoration,

00:09:20: even though they are direct or indirect is much more easy and reliable than one on ceramics if you are finishing a very very thin margin in letting they see the gate or something like that you can have.

00:09:34: Some kind of microchipping at level of the margin with an eye or exposure of the luting agent so it.

00:09:41: I can give you problems over time so for sure the general management of indirect composite restoration according to me is really really,

00:09:49: user-friendly and really interesting also because in our Dental Market in southern Italy you can.

00:09:57: Make the cost much lower than a ceramic indirect restoration so.

00:10:03: According to our patients you know we don't live in a very rich area of Italy.

00:10:09: And so we have to treat usually average people so they cannot afford 1,000 Euros for a restoration Maybe,

00:10:17: I want something more than a direct restoration and you can make them happy with this kind of hybrid situation

00:10:25: how do you lose this indirect hybrid Ceramics you already mentioned it but let's go more in the details of the luting

00:10:33: okay we have to make first of all kind of didactic classification of the materials because you know that when we talk about.

00:10:42: Indirect Restorations we mainly think about Ceramics so I think about the conventional glass Ceramics just like feldspathic just like leave side just like floor Ceramics and so on

00:10:55: but nowadays I guess that no dentists in the world would use feldspathic Ceramics for an overlay for example.

00:11:03: Because of the brightness of the material although I can tell you that.

00:11:07: If we move to the interior areas I still use Fitzpatrick Ceramics for ceramic veneers in some specific cases all these materials are achievable and this is a very very good point for the cementation.

00:11:22: If we move to other kind of Ceramics just like the polycrystalline course first of all we have to say that they are not

00:11:30: really Ceramics because if we talk about the cornea or if we will going talking about alumina maybe next year because some manufacturers are proposing aluminum

00:11:43: once again so we are going back to the 20,000 more or less this materials are extremely resistant but they are not adjustable,

00:11:52: so you know that nowadays between researchers and between clinicians there's a kind of

00:11:57: friendly fraggle about the possibility to a disabled youth this kind of restoration I mainly refer to table tops or only silver lace in lace with your cornea

00:12:10: and we can go back to this point in a few minutes in between these two classes we have all this

00:12:17: new family of hybrid ceramics that

00:12:20: mainly refer to the allowance or Pi CM so the polymer infiltrated ceramic networks we have there's a very interesting recent paper

00:12:30: bye Marcus blocks classification there's materials in a new way I refer to the clinical approach to this materials rather than to their mechanical and chemical composition and properties

00:12:43: and according to the percentage of composite or ceramics.

00:12:49: You can go for etching you can go for sandblasting you can go for coupling primers just like silence or mdp or you can even.

00:13:00: Mesh all these kind of approaches of course if you decide for example let's think about hybrid resonance Raman

00:13:09: if you want to go for etching and felt blasting you have to respect a strict workflow because you have prior to actual material and dentists and Bluffs of course and not the opposite

00:13:21: so in my opinion usually I go for etching when I have a completely glossy material so,

00:13:29: I mainly refer to feldspathic Ceramics to little cycling for Ceramics and too little I feel icky.

00:13:36: When I have to face with hybrid materials just like CLS.

00:13:41: And that case is I usually H the material although I know that the glassy phase is

00:13:49: much lower than a traditional blessing Ceramics and then I do not like to sandblast the material so I prefer to use.

00:13:58: Capping agents just like mdp just like mmm dtp or even Noble materials just like the

00:14:06: Universal self-adhesive systems whilst when I have to deal with polycrystalline course in that cave

00:14:15: as a clinician I prefer to adopt the Mind sandblasting so I use.

00:14:22: Alumina particles of 50 microns and I do not like to use the

00:14:30: conventional adhesive approach because I've seen with my eyes at the sem the scanning electron microscope that's although I make a very aggressive etching of for example zirconia.

00:14:44: I cannot achieve that Kabul like aspect to just like the glass Ceramics so in that case I prefer to go for,

00:14:55: chemical approach to a decision I mean mainly mdp I mean silent coupling agents and so on

00:15:04: at the same time I can tell you that we are working on the new system so it's more or less three years.

00:15:11: And we are achieving very good clinical results.

00:15:16: But if you go to the chemical Department of my University and you ask them may attach a polycrystalline material they say no you cannot touch.

00:15:27: In the meanwhile the development the implementation of the new molecules in the air defense systems many refer to Universal Rhythm and self-adhesive racing Samantha

00:15:40: of the latest generation I can tell you that the results right now are very very interesting I cannot tell you there are

00:15:50: completely comparable to the addition we can achieve on enamel with the 3-step system but the numerical values of addition are really really interesting

00:16:01: I always say one more thing anyway.

00:16:05: We do not have to forget that data from the lab or data from manufacturers I mean I refer to megapascal in terms of bond strength.

00:16:16: Are always recorded in a very clear and controlled situation.

00:16:21: The bench test is completely different from the adhesive cementation in a brook sir for example you can achieve

00:16:30: excellent adhesion but then during the shooing during the pair of functions maybe you will have some interference in that level of the interfacial area of addition because of mechanical stresses

00:16:44: so we have to consider that the oral cavity is a very difficult environment to be faced so

00:16:53: I've described you my.

00:16:55: Standard approach to different kind of situations in terms of muting but I can tell you that I always make very complex reasoning when I face a patient so

00:17:07: the patient related variables are the most important in guiding me to word choice of material or a luting,

00:17:17: last week I also used one of the universal luting systems and it's kind of interesting since is the AEP primer which was recommended and we're kind of told me

00:17:27: verbs this primer gives a better adhesion and the cement University cement shrinks to the tooth can you tell us what these has four for clinical advantages

00:17:39: yes I will deal with this topic in a couple of weeks at the GC mean it's important that we are going to

00:17:47: discuss online because unfortunately we cannot be in presents yet and I can tell you that the AEP is a very interesting material according to me because it's extremely.

00:18:01: Easy to use because it doesn't need any kind of polymerization it is not very operator dependent you can use it on

00:18:10: any kind of substrate I don't want to spoil anything about my future discussion anyway I can tell you that I'm using it on

00:18:19: titanium waiting for Implant prosthodontics I'm using it on any kind of no retentive preparation on teeth with any kind of material I can couple it with conventional primers or even,

00:18:32: without anything and just with the cement and I do not have right now.

00:18:38: Laboratory evidence is yet but I can tell you that from a clinical viewpoint

00:18:43: the material coupled with new Universal racing cement is very very interesting I have no experience in terms of post-op sensitivity by patients and right now.

00:18:55: Finger Crossing of course I had no no fillers no problems with the material in any kind of this restoration to that indirect in anterior and posterior.

00:19:05: And both to support it and it will support it so I guess that this will be the technology of next 20 years maybe.

00:19:14: Okay so when you look

00:19:16: back a bit of the past on your adhesive luting do you think this will change now in the future with these materials.

00:19:24: Well it will change just like the old-fashioned self-adhesive race instruments.

00:19:32: Mainly in posterior areas according to me.

00:19:36: When I talk to my students I always make a great distinction in terms of field insulation

00:19:43: so when I have to manage a complete clean substrate just like enamel in an interior area for direct or indirect Restorations are just like Trump veneers I'm still using a conventional three-step approach.

00:19:57: Not only because of the bond strength if you correctly manage the clinical procedures is definitely a liar because we have numbers telling us that

00:20:08: enamel Dentin bonding systems nowadays have the same range of megapascals in the lab.

00:20:16: But they do not have the same range of megapascals in the mouth.

00:20:19: Because we cannot control the intrinsic moisture of natural to tissues and of the oral cavity.

00:20:26: So I'm using a very good material but because of.

00:20:30: My limited skill or because of some kind of contaminants in the oral cavity.

00:20:37: You can have a decrease up to half of the megapascal bone strength values so in interior areas I still prefer a conventional three step approach

00:20:46: for sure also because I've seen with my eyes that the problems related to staining and discoloration of the margins with the three-step

00:20:56: adhesive and luting systems is very less evident over time.

00:21:02: Danny for use any kind of simplified system and I mean any kind so the two-step or the one bottle or even.

00:21:10: The universe saluting for sure and posterior areas where you have to manage sometimes

00:21:17: deep Dentin so and intrinsic moist substrate or when you don't do not tap for example very much time to work because.

00:21:27: Georg let's say not only the patients are really compliant in terms of.

00:21:33: Isolation I have different patients that when they see the rubber Dam they are kind of scared.

00:21:40: So you have sometimes to lose for example for posterior only thing you have to be quick.

00:21:46: So for sure this kind of simplified system will change our clinical approach.

00:21:51: Of course we have always to keep in mind that the conventional principles of adhesion.

00:21:57: Of direct restorative or indirect prosthodontics are the same.

00:22:01: Just like in the 80s so we have to be very precise very careful very clean and all our steps in all our technical staff.

00:22:10: Since I kind of always also know you for glass fiber posts so we have to ask you

00:22:16: luting of the glass fiber post this is a good idea to use this Universal luting presence or should we stick to the.

00:22:25: Not old-fashioned way to the standard dual key way now for sure the fiber post is

00:22:33: another word I really felt this topic because you know when I was a PhD student in China my PhD thesis was about fiber perso.

00:22:44: We have dealt with this topic for more than 15 years and I can tell you that nowadays I still use Fiber posts.

00:22:53: And very very.

00:22:56: Different clinical situation and since my first glass fiber post I've always used,

00:23:03: Seth for these it cements so because yes you have to because of the.

00:23:08: The quality of addition you can achieve in a root canal is very very different from.

00:23:14: The addition you can achieve on superficial Denton because of the anatomy of the dent so I've always preferred to use this kind of simplified systems.

00:23:27: Although I can tell you that,

00:23:29: going against the Detention of the manufacturers I always make a kind of The Grieving of the root canal before making my Edition,

00:23:41: and they can decide to decrease with ethanol for example so I generally use 96 96 percent ethanol.

00:23:50: So just robbing and brushing my brain still thinks I do root canal and then waiting for the air to do

00:23:59: all the job all sometimes I use phosphoric acid but I'm not intended to,

00:24:05: etch the root canal Denton I just want to clean from the.

00:24:09: To clean it from the debrief and then I use a One-Shot approach so I generally use simplified dual Curative systems

00:24:21: of different brands and I do not like to.

00:24:26: Light cure inside root canal the bonding agent because we have seen that many many times you can achieve a kind of

00:24:35: increased thickness that can interfere with the interfacial addition of the fiber post so I prefer just to place my bonding and very quickly I

00:24:44: put the cement inside the canal and on the tip of the post and I use the post to gently push over the canal the.

00:24:54: The cement that,

00:24:56: I can tell you that the self-adhesive cement or nowadays the universal cements are for sure the first choice for this kind of approach according to me

00:25:04: interesting although usually in the past I used like the premium bond with the DCA one I still like cute it

00:25:12: because I was told it has some benefits if you like cured so you would say.

00:25:19: Your recommendation is not to light cured at all well it's not a recommendation it depends it also depends on the type of post you're using.

00:25:31: I'm using the kind of system that is in the shape.

00:25:36: Exactly identical to the bird used to prepare the double space.

00:25:42: And I've seen in my samples that many times if you so kind of tick bonding agent you can achieve at the tip of the root canal some increased thickness but.

00:25:54: It's completely up to the operator I can also tell you that many manufacturer producing simplified race instruments.

00:26:03: Advise not to use the bonding so you just use the racing treatment and everything is up to the cement so I guess that you can

00:26:12: choose in between the two approaches according to your attitude basically I still recommend use of bonding

00:26:19: instead of the solid estimate because I know that you can increase the flow ability of the cement inside the root canal don't forget that a root canal is

00:26:31: a very very deep first class so we have received Factor very not advantages for the

00:26:38: polymerization shrinkage so I mainly use the bonding to increase the flow ability of the cement rather than 4,

00:26:45: purely addition okay you might get some questions from you to your lecture I'm pretty sure about that

00:26:54: you know that Leticia and all the GC staff asked me to present something about fiber ports but I'm not sure after this discussion with you.

00:27:02: Noah just joking for sure we will we will have so many topics to discuss during the mini Symposium it will be interesting for sure

00:27:10: Michelle you attended the mini Symposium during my lecture or not.

00:27:15: Well I'll do it there's no reason not to attend just look up your title of your lecture

00:27:26: G someone the one that set by a simplified approach I think you

00:27:30: already teased a lot for your lecture I think everybody is quite excited yeah yeah yeah I've definitely we have and I as usually have a great problem because.

00:27:41: I am used to

00:27:43: cut and paste my lectures during the last night before the presentation why is this time I have to make everything quicker but I'm a good.

00:27:52: It may be within tomorrow I will finish the outline of the presentation for sure although I can confess that I have

00:28:00: one case that they will cement next Tuesday and I would like to put some pictures of this case because it's interesting we will see okay.

00:28:10: In my lecture always try to have a case of the same week so I can tell them basically that's how I do in some cases I can't show

00:28:19: just as can show a five-minute follow-up for last yeah just a five-minute fold up when you can tell everybody but let's see how it will look in the year right now I like this part I didn't like this part and yeah.

00:28:34: This way due to the pictures you can see in one year or maybe five years if you still kind of like this case and you have pictures to show it's always good I always when I look at my pictures of one week before.

00:28:48: I'm always not satisfied because I always want to reach something more something more that you know I'm convinced that.

00:28:57: We can learn from everybody and in any case for sure so we just have to go a little further a little further for

00:29:07: day by day in our clinical practice the aim of this lecture will be 12 just like some clinical cases to show out the G someone

00:29:18: can be really versatile as regards the follow-ups I agree with you that if you.

00:29:27: Perform your clinical step wisely and I'm sure that we we are average dentist but we try to do our best every day I guess that the.

00:29:37: The characteristics of nowadays materials are really reliable so I'm pretty sure that.

00:29:43: If you made a very good restoration just like yours because I've seen your lectures and you are.

00:29:49: Top-notch restorative dentist I'm sure that in five years you will have exactly the same picture maybe with a little staining because our restoration

00:30:00: what leave with our patients so it's.

00:30:03: Normal date the Aging will occur for sure but I'm pretty sure that five minutes for two-year follow-up will be.

00:30:11: More or less the same so I'm looking really forward for a lecture Roberto thanks a lot for your time thank you very much and.

00:30:19: Now thank you for dedicating some time on Saturday to discuss thank you to actually we could a little that's quite a the early today so it's nice to have a start with nice weather today

00:30:32: yeah Germany will be nights weather today.

00:30:35: Yeah what about the way they're in Germany year in Italy today it will be nice okay great great great because here in Italy until one week ago it was still.

00:30:47: Spring Lake spring but it's two days that it's just like summer so it's very nice to go out just for a work because you know we have some restrictions yet but we can go out for.

00:30:58: For Works to the fee fight so that's actually.

00:31:02: Last week we even had snow in some parts of Germany so it was a mix of rain and snow and everybody fought well this can't be true

00:31:12: wow then I'll say goodbye and see you soon online.

00:31:16: Thank you very much George have a nice weekend and thank you for your kindness and see you very early by.