Pascal Magne On Occlusal Veneers And Material Selection

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Pascal Magne on Occlusal Veneers and Material Selection – PDP221

22d ago 1:26:44

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Can composite really outperform ceramic in the right case?

Do you know when to choose an inlay over an onlay?

What makes occlusal veneers so effective — even at just 0.6 mm thickness?

After years of anticipation, Dr. Pascal Magne finally joins Jaz Gulati on the podcast for an episode packed with adhesive dentistry gold. They dive deep into occlusal veneers, material selection, and why indirect composite may be the best-kept secret for worn, root-filled molars.

They also unpack the full bonding protocol step-by-step—from air abrasion and IDS to silane application and cementation with preheated composite. Whether you’re doing full rehabs or composite repairs, this episode is your go-to guide for smarter biomimetic dentistry.

https://youtu.be/WTsF1mD-nTo

Watch PDP221 on Youtube

Protrusive Dental Pearl: After applying silane, don’t just let it evaporate—let it react for 30 seconds, then air dry, and crucially, use a heat source (like a hairdryer) for 60 seconds to activate it properly and achieve optimal bond strength. This enhances the effectiveness of silane and significantly improves the bond strength of indirect restorations like composite or lithium disilicate.

Key Takeaways:

Occlusal veneers can be as thin as 0.6 mm.
Indirect composite is often a superior choice for restorations.
Proper bonding protocols are crucial for successful restorations.
Focusing on strengths rather than weaknesses is key in dentistry.
Conservative approaches in dentistry can preserve tooth structure.
The vital tooth is always preferable to a non-vital tooth.
Composite resin has wear properties similar to enamel.
Occlusal veneers provide excellent protection for compromised teeth.
Porcelain veneers have long-term durability compared to composites. The evolution of composite materials has led to better options for restorations.
Zirconia is strong but difficult to adjust and bond effectively.
Immediate dentin sealing is crucial for successful bonding and patient comfort.
The Dahl principle allows for minimal preparation in certain cases.
Composites can be as effective as ceramics when used correctly.
Understanding the properties of materials is essential for successful restorations.
Thin occlusal veneers can be successfully bonded with proper techniques.

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

Highlights of this episode:

0:00 Introduction
02:52 Protrusive Dental Pearl
04:42 Dr. Pascal Magne on His Current Focus
10:16 Understanding Cusp Coverage and Material Choices
15:48 Conservative Approaches in Dentistry
23:16 Unsupported Enamel: Can it Still be Reinforced?
28:05 Occlusal Veneers Indications
37:00 Material Selection: Composite vs Ceramic
01:24:42 Outro

Referenced Studies – all below are available to download on Protrusive Vault in Protrusive Guidance

Effect of immediate dentine sealing on the aging and fracture strength of lithium disilicate inlays and overlays
Short-fiber Reinforced MOD Restorations of Molars with Severely Undermined Cusps
Ultrathin CAD-CAM glass ceramic and composite resin occlusal veneers for the treatment of severe dental erosion
Strains in the marginal ridge during occlusal loading
Antagonist Enamel Wears More Than Ceramic Inlays
Outcomes of resin-bonded attachments for removable dental prostheses
Performance of ceramic laminate veneers with immediate dentine sealing

Keep the learning going with Magne Education

If you enjoyed this episode, don’t miss A Geeky Discussion on Adhesive Onlays – that’s PDP161!

This episode is eligible for 1.25 CE credit via the quiz on Protrusive Guidance .

This episode meets GDC Outcomes B and C.

AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY (Indirect restorations)

Aim: To provide clinicians with evidence-based guidance on occlusal veneer indications, material selection, and conservative restorative protocols—emphasizing the role of adhesive techniques and biomimetic principles in long-term success.

Dentists will be able to –

1. Differentiate between inlays, onlays, and occlusal veneers, and select the most conservative option suitable for each clinical scenario

2. Make informed decisions on material selection based on occlusal anatomy, antagonist material, and long-term clinical performance.

3. Assess the biomechanical behavior of composite vs ceramic materials, including their effect on stress distribution and enamel wear

Click below for full episode transcript:

Teaser: An onlay is always going to make the tooth stronger than an inlay. However, the chances of catastrophic fractures with an onlay are bigger than with an inlay. And I know it's not unanimous, some of my colleagues, they don't like the fact the composite has a lower elastic modulus. But again, you have to understand a non-vital tooth is a handicapped tooth.

Teaser: So the damping affect the damping behavior of this occlusal volume of composite in our studies actually proved to protect the remaining tooth structure at the level of the root. With the occlusal veneer, there’s no need- Element of biomimetic dentistry is to say that the restoration should be allowed to fail in order to protect the tooth. Zirconia is the opposite.

Jaz’s Introduction:
It finally happened. Finally got Dr. Pascal Magne on the podcast. If you remember episode 100, I was in Edinburgh at the BACD in the queue to get my book signed by Dr. Magne. And I said to him, please, will you come on the podcast one day? And that day finally came a few years later than I wanted, but we finally made it guys.

And let me tell you guys, you are in for a treat. We’re talking about occlusal veneers. How thin can you go? Like think of a lower molar that is worn and is spawn into dentine possibly because erosion and attrition and you don’t have much space and you don’t really wanna prep so much, we can go as thin as, let’s say 0.6 millimeters.

And what if I told you, you can do it in indirect composite? And that’s probably in many cases, the preferred choice. At the end of the podcast, we discuss the exact protocol of bonding and indirect composite which actually is also gonna help you if ever you’re doing a composite repair, how to bond new composite to old composite.

Now we covered so many geeky adhesive and restorative themes, like why not use zirconia? Why is indirect composite a superior choice, especially for your root filled molars that need cuspal coverage? Which is interesting because I have been doing lithium disilicate for many years thinking that composite was like a cheaper option, was like a second rate option.

Actually, Dr. Pascal Magne says that if it was his tooth, he’d want indirect composite. Well, you are in the right place to find out why he said that, and also why we should not be so aggressive in capping cusps.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your Favorite Dental Podcast. If you’re returning again, thank you so much for being a Protruserati. If you are new to the podcast, you picked a really good one. I’ll tell you what all our podcasts are awesome, thanks to the wonderful guests we have on, so please don’t forget to hit that subscribe button if you like what you hear or see today.

Dental Pearl
Every PDP episode, I give you a Protrusive Dental Pearl, and today’s one is of course inspired by Pascal Magne and an adhesive protocol tip. The tip is when it comes to the silane step, that step is so critical in whether you’re bonding an indirect composite or an indirect ceramic such as lithium disilicate. Once you’ve done the correct surface preparation of your indirect restoration, so that’s different for composite, which you’ll hear at the end, and that’s different for ceramic.

And once you get into the silane stage, here’s what you don’t do. You don’t just apply silane and leave it on the side to let it evaporate. No, you want to let it react for 30 seconds, then you want to air dry it. But then you want to use something like a hair dryer. You need to use some hot air to achieve the perfect layer and the perfect chemistry of your silane.

And this surface preparation with silane, such a critical step that it makes a huge difference in the bond strengths you can achieve. So makes your guys that you are air thinning your silane, and then you’re using some sort of a heat source to achieve that optimal layer. And you’ll hear about the the geeky justifications and the steps for this towards the end of this podcast.

Do not go anywhere, guys. You’re gonna enjoy this a lot. And remember, our episodes are eligible for CE. This episode is worth 1.25 CE credits, and we are a PACE approved education provider on our platform, which is called Protrusive Guidance. The website for that is protrusive.App. That’s www.protrusive.App. You’ll have access to over 350 hours of CE.

This includes the podcast episodes, but also our mini courses and on demand webinars, which are thoroughly enjoyed by our members. So we’ll remind you at the end how to claim CE for this episode and all the others. Let’s now join Dr. Pascal Magne to dive deep into occlusal veneers. I’ll see you in the outro.

Main Episode
Dr. Magne, we had that mentorship session about, I don’t know, six weeks ago or something, right? And I didn’t tell you this at the time. But I only slept for two hours that night ’cause my baby was up and he was very sick the whole night, right? And I was exhausted the whole day. But I knew that I was speaking to you and my wife could tell that there were the energy levels.

As our call was coming, my energy levels were rising again. And it was so great to spend that hour and a bit with you. And it was so great to see you in London last week. You’re an absolute inspiration. You’re a man who needs no introduction. Like you, your legacy is so much in academia. You are the author of a most fantastic book, and-

[Pascal]
Thank you.

[Jaz]
It’s a great pleasure to bring you to the Protrusive Dental Podcast. How are you feeling now that you’ve done a little mini tour of Europe and back home now?

[Pascal]
Yeah, I’m good. I’m great. Back to Europe very soon, actually, in a few weeks with the Barcelona, two days lecture there, but I’m good. I’m good. I travel a little bit less than in the past because now we focus on our center here at home in Los Angeles, Beverly Hills, more precisely. Our new center, Magne Education, where I try to focus on hands-on education.

We have also online education. We have a whole bunch of programs, and you see, this is my focus, but I still travel, let’s say. Approximately eight times a year overseas for lecturing and different things. Yeah. But otherwise, it’s great and exciting to be a dentist in those new times. Amazing technology coming out. Artificial intelligence.

[Jaz]
You make it exciting, Dr. Magne, honestly, with everything that you’re sharing, you honestly have that effect. I’m sure you hear that all the time. Today we’re talking about something very cool. Occlusal veneers, like I’ve done injection molding posteriorly.

I have never done these ultra thin occlusal veneers, so I really want to learn a lot more about them. And before I dive in, just as part of the introduction, I wanna just heart to ask you this one thing, because you’ve done so much in academia and now you’re running your training center, which by the way, just looks spectacular. I hope to visit you one day there as well. Do you miss the academia?

[Pascal]
Yes. I have to say there are some aspects of academia that I miss more than others.

[Jaz]
Let me guess. Your students?

[Pascal]
My students. Exactly. So, my students, I consider them like my babies. And I’ve had so much satisfaction teaching. Really teaching is what I like doing the most. Sharing knowledge. Of course there is research, but I still do research a little bit less than before. But, research was also a big part of my academic life, so having visiting scholars from all over the world to join. So I consider them also my students.

So yeah, these things, I miss a little bit. I don’t miss the politics and the committee meetings and all the things, I think that’s what’s beautiful with aging. To try something positive, to try to find something positive about aging is when you’ve been successful, you end up choosing more what you like.

And discarding what you don’t like. And again, with age, you come to do more and more. What you’re good at and less and less what you are not necessarily good at. And that’s always my advice to the young generation is to focus on your strength. Because you will never be good trying to improve your weaknesses.

You will never be as good as developing your strength. And that’s what I think maturity is bringing you to do more and more what you are really good at and less and less the stuff that are more distractions, you know?

[Jaz]
It’s like niching down and we talk about that on the podcast a lot about and finding your niche. Have you ever read this book called Strength Finder?

[Pascal]
Exactly. That’s where I’m getting my inspiration. I actually did a whole retreat.

[Jaz]
Oh, no way.

[Pascal]
Actually, with my wife, because the goal was to develop the strength in our relationship. So we both did the strength finder assessment and then based on that, to try to put our strength together and coming to the conclusion that if you have the same strength actually is not an advantage. It’s better to have different strength in different areas and put them together as a couple. And that’s what we learned at this amazing retreat, which was interesting because we did that through the church, but we had to do the strength finder assessment, which I really recommend to everybody.

[Jaz]
Me too.

[Pascal]
If you don’t know yet your strength, but you should by now, you should know what you’re really good at and it’s the same with the left and the right side of the brain. You remember when I was in London? We talked about that. Some of us are more analytical, temporal, and then some others are more creative, and we have to put that together in the best way possible. And it’s called balance, right? It is like an aesthetics left and right. Left and right side of the brain have to be in balance.

[Jaz]
I love how you made that connection with taking it full circle. Once again, a great lecture in London last week. Today’s topic is a hot one, occlusal veneers. But before we get to that, I wanna talk about more of a daily scenario, and then I guess we can evolve into occlusal veneers. I bet one of the most common questions that you get asked all the time is Dr. Magne, when I’m doing an overlay on a lower molar, let’s say it has an MOD amalgam, let’s say it’s root filled, and you’ve decided that you will be cusp capping the buccal and the lingual. How much should I do my occlusal reduction for my restoration? i.e. How thick should I have my lithium disilicate?

[Pascal]
So we’ve studied that quite extensively. And to be honest with you, it’s a very difficult, even with the science, it’s a difficult question to answer because it’s a little bit. I like there, there were a few original studies by a fellow in Holland called Fennis, F-E-N-N-I-S, Fennis, and I got a lot of inspiration from his publications, and they were about overlapping, this is not overlapping, a cusp, which is the everlasting debate, right? When to overlap, what’s the residual thickness of the cusp that should be overlapped or not.

And dentist, we are very analytical, so we want recipes and we want to say, okay, if the cusp is this amount I should cover is this amount, I can’t keep it, et cetera. And things are not so mathematical as it appears. And let me tell you why. Because we know that the biggest variable in any procedure is the operator and not necessarily the material.

Okay? There are choices we have to make with materials and we’ll talk about that. But still, when I look at research articles. The problem I have is, let’s say there’s an article about overlapping versus, oh, not overlapping cusps, weakened cusp cracked cusps, and they are using a different bonding protocol than my protocol.

They are doing an inlay, but without immediate dentine ceiling versus an onlay, you know? And now you are not comparing what is actually what you are doing clinically, right? So that’s why for a lot of those research we had to do our own investigations with our own bonding protocols. Because as you know, it’s all about the protocols and how strict you are with your bonding protocols.

And there are so many ways of bonding today. And there are, maybe, I don’t know, it was like 10, 15 years ago, we counted like over 100 dentine bonding agents on the market. I’m sure it’s much more than that today. And most of them are poor products.

[Jaz]
Wow. I did expect you to say that. Wow.

[Pascal]
Yeah. There’s only a certain, a limited amount of adhesive that have a proven long track record. And so imagine your question is diluted in this whole approach. And what’s going to be, you see, for instance, there’s a good study by my dear friend Marco Gresnigt and still in Holland. I tell you the dentist, some of the professor in the Netherlands are really good.

They ask the right questions and I follow their research. And Marco is also one of my students in the sense that he came to my lab to do some of the research about veneers. And I contributed also to his articles about onlays. And he was showing clearly that if you do an inlay with immediate dentine sealing, this inlay will make the tooth as strong as a an onlay without immediate dentine sealing.

You see what I mean? So the stronger you bond, the less those decisions are important. They are equations in adhesive dentistry, like the stronger you bond, the less important your preparation. The less important is a choice of overlapping versus not overlapping a cusp.

The stronger you bond, the thinner your material can be. The stronger you bond, the weaker your material can be. The stronger you bond, the less you need retention, resistance form. And today there is all these materials because there’s not only the question inlay versus onlay, but then there is composite versus lithium disilicate versus zirconia versus all of this.

So the question is huge. And I would like to say personally, I could pull out articles that say, bond well and you can do inlays even in non-vital teeth. And articles that say, no, no, an onlay is always stronger than an inlay. And in general that is true by the way that an onlay is always going to make the tooth stronger than an inlay.

However, the chances of catastrophic fractures with an onlay are bigger than with an inlay, you know? So when you overlap a cusp, you make the tooth stronger, but when is going to fail? In case of overload, in case of overstress and there is a crack that will initiate, this crack will more likely end up progressing subgingivally.

And rendering the tooth much more complicated to re restore, right? So your question is more like, choose your poison, in other words. An inlay more conservative, maybe less strong, but more re restorable. And that’s where I stand personally. Just as a personal story, I have a two teeth in my mouth and both upper maxillary molars that had big MOD amalgams, they are very likely the tooth you were talking about.

And, I have not an ideal bite like most of the dentists, right? We strive for the best bite for our patient, but we don’t take care of our own bite. I’m class two with overjet and stuff and no anterior guidance but guess what? I don’t have a single root canal treatment yet in my mouth.

And to me, that is the victory. That is the victory, is to have all your teeth vital. Because we know that the vital tooth is always a winner, and the non-vital tooth is always a loser. And what I like to say is, if you have a non-vital tooth, you cannot win the Olympic Games of restorative dentistry with that tooth.

It is a handicapped tooth. So the goal is really to prevent that first root canal treatment is to prevent that first crown, is to prevent and be conservative. So just to be honest with you, I would always choose an inlay over an onlay because I can always do the onlay later.

It’s like I will always choose a direct composite over a more invasive preparation. Then I can do a more invasive preparation. So we realize that you always wanna have one solution left after, right? And you don’t wanna be in this place where, what do you do after the crown usually is extraction if you have already a root canal, et cetera.

So that’s why we stop doing those invasive preps. And I know that, you know, and social media is opening so many windows on what is happening in the world with your question precisely, which is onlay versus inlay. And when I see so-called biomimetic dentist advocating cusp, aggressive cusp coverage in a way that you end up cutting off intact tooth structure more than you would for an occlusal coverage of a crown, then I would never call that biomimetic anymore.

So then there is the topic of thickness of the cusp. So when is it that the onlay is unavoidable? When is it that the only is unavoidable? For me, for the only to be unavoidable, I have to have extremely severe signs of suffering of that cusp. When you see the occlusal surface has been really beaten down, the enamel is already cracked and crumbling apart, you have cracks going underneath the cusp, visible on the outside of the tooth from the inside to the outside.

Those are signs that okay. I have to consider the onlay. Now, the thickness of the cusp to me is rarely the reason to be honest with you. Because we’ve done some research about super compromised cusps and very thin only enamel left. But when you do immediate dentine ceiling. And you restore the cuspal thickness with your buildup.

And nowadays we know our latest research is about fiber, short fiber, reinforced composites like ever X. When you use those material to give back the thickness of the cusp, then you new thickness if you want, is the one after the buildup. And now you can restore that. You can fill in those undercuts. You can make that cusp strong.

Even if you have to wait for this inlay to be processed. Whatever is your technique, maybe you have to wait for 10 days or two weeks that buildup with immediate dentine ceiling, using the right product, using the right protocol will make that cusp strong enough for that interim. And then the final strength given by the bonding of your inlay.

So back to my story. I had two MOD amalgams on my first maxillary molar that became sensitive because of cracking inside the dentine. So cracked two syndrome, enormous pain in biting air, cold, warm. Anything would hurt. And I was like, okay, my time has come for my first root canal. No, we bonded it. We did inlays actually back then. I of course said a colleague of mine-

[Jaz]
Indirect inlays. Yeah? So ceramic inlays.

[Pascal]
Yeah, indirect inlays. They were in composites. I made them myself on a fast setting silicon model. And one was a silicon model, one was a stone model. Anyway, I did my inlay with my regular clinical composite.

Nothing fancy, but a hybrid material. Micro hybrid, nano, hybrid style. Back then, it was 25 years ago, and more. And so, and that was bonded. And guess what? 25 years later, both teeth are still vital. And I am, again, if you see these occlusal surfaces, I’ve still kept wearing my teeth. I will be ready soon for my occlusal veneers.

But you know, I’m 59 and that may be the next step. Let’s not burn the steps. That’s my problem today is when we go straight to the invasive solution and my old mentor, Dr. Belzer, always told me, you know, Pascal, you always need to have a solution left at the end. So don’t burn the steps.

Don’t go too fast and people ask me all the time, ah, this aesthetic is, should I do composite resin direct or ceramic veneers? Well, if you are asking, that means start with the composites. You can always do the veneers later. And same thing. I look at social media today and sometime I feel bad for those patients who received 10, 12 veneers.

Now the first molar also veneer then like a 12 pack of veneers when that could have been the next step. Not now. Not as the first restoration on those teeth, you know? And so we need a lot of wisdom when it comes to those decisions. So I know it’s not a short answer to your question, and maybe it’s not an answer at all, I don’t know.

But I would always choose the most conservative solution first, knowing that a failure of that solution will most of the time allow you to still perform the next one. So a failure of your-

[Jaz]
That gives it justice. ‘Cause we can’t just give a number sometimes. Right? And you made a great point that, and you taught me this last time in our mentoring session as well, that the inlays that are well bonded, following a good protocol, they will significantly reduce that cuspal flexure. And we don’t necessarily need to cap those cusp. So for me, that was really good to hear. My only worry is if someone takes that information away. And what do you feel about the situation they’re presented with is that the enamel is like, by the time you move the caries and the old amalgam, the enamel is now unsupported. There is the full thickness of enamel where there’s no dentine. Are you still okay to reinforce it with fibers and IDS?

[Pascal]
Absolutely. Yes. Yes. And actually, one of the studies we did about Ever X was about really totally undermining the cusps and using Ever X to build back the missing dentine. Short fiber in force composites are the best dentine replacement today because of their fracture toughness. I think the team of Dr. Pekka Vallittu in Finland, in Turku, they did an amazing job in establishing a standard for the size and shape of those fibers. You know, what they did is really because, by the way, a short fiber-reinforced composite is nothing new.

In the nineties, there were at least two materials that I know, Alert and Restolux. They were short fiber in force material, but the fibers were chopped so short that the fibers were acting more like a filler rather than a fiber. And Dr. Vallittu and his team, they came up with this formula where they say, when the fiber is 70 times longer than the diameter, then it’ll behave like a fiber.

And so that’s the value they established for their first product, which was EverX Posterior. And we tested this material. I was totally surprised by the results and this material. But then the thing is, with this size of fiber, the material becomes a little bit viscous and you would have to preheat it to place it.

And you could actually not mix it, but combine it with flowable composite so that the areas, and if you have a complex cavity with lot of little extensions and stuff EverX posterior might not go everywhere there. So you wanna line first the preparation with a little bit of flowable composite.

Now they have EverX Flow and EverX Flow, by the way, is the only version we have in the US. The officially EverX Plus is not sold in the US. It’s approved by ADA, but not sold. So if you combine EverX Flow to fill the bottom of your preparation and you can leave it un polymerized and then use EverX posterior preheated.

It’s easier to place and you have a wonderful dentine replacement with the material, the fibers of which will act really as a reinforcement. And to me, I would favor that over continuous fiber. I’ve never been a big fan of continuous fiber. We tried it, we did some research. We could never get the result we got with the short fiber. And it’s simpler to apply.

[Jaz]
Do we have any clinical data to back this up of using short fibers to replace the dentine and then having that unsupported enamel and now supporting it with the fibers. Do you have any clinical longevity data?

[Pascal]
Yeah, absolutely. And the Turku team actually, they have clinical data now. They are even looking at the next step, which is using, because the flowable material with the very short fiber, the flowable material. The thing is they did a compromised. They made the fibers smaller and shorter. So now the fiber length by diameter ratio is a bit less for EverX flow, it’s only 30 instead of 70.

That’s why the material flows more, but there is more fiber inside. And what it is, it makes the material always almost polishable, which is really amazing because of course you would never use EverX Posterior to the surface of the two. But EverX flow might be possible to use. All the way to the surface, and they are investigating that.

So yeah, the reasons are extremely encouraging where yes, we need more clinical result, but it’s coming. And honestly, I’m very confident based on the in vitro result we got with this material. I really see no reason why the clinical results should follow the same trend. And I think that this is making a huge difference.

Now, back to your question, how those inlays are being prepared, the base liner, what adhesive system you use, all of these are very important parameters in addition to your own hand, right? So we have to be careful when we read any research article that we are considering all those elements together.

[Jaz]
Excellent. And now we can move towards the main topic which is occlusal veneers, right? So what would you say is, are there indications for occlusal is because we said now that in that made up scenario of the lower molar with the MOD amalgam, that actually what the lesson to learn from, from when you answer that is try to preserve the cusp where possible, unless it’s looking like it’s stressed. And just on that actually, if it is stressed and you are gonna cap it, how thick do you want your lithium disilicate over that cusp.

[Pascal]
Right, exactly. So that was what we studied in a number of studies, especially with my dear ex-student and friend and now colleague and professor Luis Schlichting , who is from Brazil, but now teaching at the University of North Carolina in Chapel Hill.

And with him, PhD actually, topic was that questions, how fit we can go with those veneers and depending on the material. So we started with in vitro data and we did a lot of experiments using different materials from composites to Empress, cAD, Emax and even some fiber in force composite at that time.

But anyway, so we went from 1.2 millimeter down to 0.6 millimeter with those venues. And what was really fascinating, because this series of experiments followed another series of experiment when the teeth were non-vital, and we are doing like thick onlays, like three millimeter occlusal coverage on non-vital teeth, simulator tooth, that it’s really been beaten down.

The cusps are already gone. And you do more like endocrine type onlays if you want. And those Endo-Crown type onlays, whether they were in ceramics or composite, we were able, according to our load protocols, we were able to break them. And we have a load protocol that’s well established.

We start loading those teeth at 200 Newton, then we go 400, 600, 800, 1000, 1200 Newton. We keep ramping the load until we have a failure, right? And usually, I think we went to 12 or 1400 Newton, and then we stop and we see how many teeth survived. Well, with a non-vital teeth and those different onlays, we never had teeth surviving the test.

However, with the occlusal veneers. Guess what? We had all the teeth surviving the test, all of them with the same load protocols. We could not break them catastrophically. And that tells you why. Why? Because in the other group of experiment, the teeth were non-vital. The teeth had lost a lot of structure.

We were dealing with what I told you before is called a handicapped tooth. A nonvital tooth with a lot of structure lost. So this tooth starts the race really with a huge handicap. The occlusal veneers, we did them on intact wisdom teeth with the molars with a minimum reduction. So the main coronal structure was intact.

Only the occlusal part was re substituted with the different materials. So result, because the main structure of the tooth was intact, the pulp roof, the enamel dome and all that stuff was intact. The teeth survived. No catastrophic failure. Not even a fracture of, let’s say, a piece of the occlusal veneer coming off. The only thing we observed-

[Jaz]
So that’s why I wanted to ask. I was saying, did the restoration failed, but the tooth survived? But you’re saying actually the entire complex survived.

[Pascal] The entire complex survived. The only thing we were observing was cracks in the restoration cracks. And we always considered the cracks more than three millimeters because less than three millimeters really, nobody will see them necessarily.

Okay. So this is amazing. So this is the first message for you, whether the veneer was 1.2 millimeter down to 0.6 millimeter, the only thing we could see were cracks. And what was surprising in this case is that the ceramic, even Emax, had more cracks than the composite veneers. So this was really surprising. The composite occlusal veneers, thin ones displayed very little amount of cracking.

[Jaz]
Now with the composite then that’s very fascinating. But this is a different beast. I just want people to understand that. Would you have expected the same result? If something like genial injectable was used in a direct technique and then cured through like a stent, but because you’re using an indirect composite, that that gave it a more superior mechanical properties. Would you expect the same result from a direct?

[Pascal]
No. Direct composite is a different animal. Direct composite is light cured in the mouth. The degree of cure is not as good as a CAD/CAM milled occlusal veneer like the ones we did. So the degree of cure is less, is less dense. There’s porosities, there is imperfections.

And actually we also tested that in the previous group of studies with endodontically treated teeth. So, by the way, in those studies about thick onlays on endodontically treated teeth, the winner was very clearly the composite. And I like to say on an endodontically treated tooth, I like the idea of having the composite act as a stress absorber.

And we had like this effect of absorbing the occlusal load by deformation and protecting the root structure. So with the ceramic, we had more of a stress transfer straight into the root and more subgingival fractures also. So I like the idea of the composite, and I know it’s not unanimous. Some of my colleagues, they don’t like the fact the composite has a lower elastic modulus.

But again, you have to understand a non-vital tooth is a handicapped tooth. So the damping effect, the damping behavior of this occlusal volume of composite in our studies actually proved to protect the remaining tooth structure at the level of the root. With the occlusal veneer, there’s no need of such a protection if the tooth is pretty intact.

Like say I’m talking, we talk like a tooth that maybe had a root canal, like just a little axis occlusally, but the endodontist, and then you were asking me, what are the indications, right? So a typical example is the patient went to endo as an emergency. What do endodontists do? They reduce the cusp immediately to prevent fracture, and now you are missing like half a milimeter of enamel on that cusp, maybe more.

And that’s where the occlusal veneer is fantastic. Now you have- for patients who might not be able to afford an occlusal veneer. You could do also what I call an addictive composite. You can extend the composite over the cusp and if it’s well bonded and it’s thick enough, it’ll serve the patient well for many years. And I’ve done that in-

[Jaz]
But it has to be thick enough. Therefore, if the endodontic has just shaved it half a millimeter, then you’re gonna have to then shave it down a bit more. So what thickness of the composite are we looking for in this additive?

[Pascal]
Yeah. When I meant, thick enough, I meant in the central aspect because where are those restorations going to fail? Mainly, in the central groove. And so you wanna be very careful. You see, that’s another element that makes the question tricky is about occlusal anatomy. So when you have a very deep mesial distal groove, there is more chances of the tooth splitting than when you have strong marginal ridges. And strong transverse ridges.

So when you build your anatomy, it’s very important to reproduce those structure. And so that’s why we know that. And there’s lots of study by a fellow from Australia and or New Zealand. They called Messer, M-E-S-S-E-R. And they were actually also in Minnesota when I was doing my PhD there. And they show that if you have intact marginal ridges on a posterior tooth and you have an endo.

Preparation and endo treatment, but the marginal reaches are intact. You need nothing else than an occlusal composite because of the remaining structure protecting the tooth. But it might be that the endodontist has reduced those cusp and in that case you could extend the composite or you could do an occlusal veneer.

The occlusal veneer definitely will be a little bit of a plus in terms of protection and for the choice of the material. That’s another important decision you have to consider occlusion and antagonistic wear. So if the tooth facing that onlay is a natural tooth with enamel, I would always choose composite because you have to look, there is a very good study about wear of antagonistic cusps.

So you have to look at the wear as a volumetric wear. That’s very important because most studies they measure wear, height of wear. And you have to understand, and I try to explain that in my book Depth of Wear is an occlusal property. Because imagine when you have a very, very pointy cus you will lose a lot of height, but not necessarily a lot of volume.

When you have a wide cusp, you might lose less height, but still a big volume. So the depth of wear is an occlusal property. But what is characterizing a material is the volumetric wear. So when you look at this study and there’s excellent study by Kunzelmann in Germany, Kunzelmann, and they look at enamel wear against different materials, but they look at the volumetric wear and suddenly you see that enamel against composite.

It’s 50/50. You will see 50% on one side, 50% on the other side, and the total wear, the additive wear of those two volumes is always going to be less than with ceramics. So if it’s ceramics, the ceramic itself will wear its itself very little, maybe only 30% of the total wear, but the 70% or more will be the wear of the antagonistic enamel.

But the fact is that this 100% of volume loss will be much bigger than with composites. So when people ask me what is the most biomimetic material in general, I tend to say the most biomimetic material is composite resin. Why? Because composite resin has wear properties very similar to enamel and elastic modulus, which is the damping behavior of the dentine.

So wear and damping behavior, and that’s what makes the tooth very unique. The enamel resists wear the dentine is a damping structure to absorb the deformation. You see, you lead the Protrusive podcast, right? Your topic is occlusion. So this is modern. I call this modern gnathology.

It involves biomaterials. Understanding that occlusion is not just cusp touching occlusion is the biomechanical response to occlusal stress. And that involves how the tooth, the forms under load. Imagine implants. Now, implants is a bio mechanical challenge because there is no damping behavior except for the supporting bone.

And that’s why there are some studies that says, oh, short implants are great because they have more flexibility because it’s shorter. It gives a little bit more deformation, right? Now that’s not necessarily good for the bone, but it’s good for the occlusion because it gives a little -. I always say myself, if I needed an implant one day, I would have a composites in crown on that implant.

Because we measured that the damping behavior of a composite crown makes that implant respond biomechanically similarly to a tooth with a PDL and intact dentine, et cetera. So back, I know it’s a lot of-

[Jaz]
Before you continue though, just the thing that’s going through my head, Dr. Magne is, how many dentists in the US and around the world, they see composite as a second grade material.

And actually, I’m just, while you’re talking, I’ve gone back to a podcast I did three years ago, it was called Composite Veneers versus Edge Bonding. And we talked about biomimetic dentistry with a very talented British dentist called George Cheetham. And one of the comments was the words biomimetic and composite do not belong in the same title.

[Pascal]
That’s interesting.

[Jaz]
And so there are these strong opinions that everything has to be lithium disilicate. So it is very fresh to hear your views.

[Pascal]
Yes, yes. So my statement was not against ceramics. ‘Cause there is a room of course for ceramics and when we speak about porcelain veneers, for instance. There’s no doubt that nothing can beat porcelain veneer in the long run. When I see my patients 25, 30 years later, the ceramic still looks great. I cannot say that about the composites. But again, it’s about respecting the steps and I think that in young patients, adolescents, why would you do veneers in adolescents?

This is a nonsense to me. You can unless it’s a very, very bad, severe problem, general dysplasia of enamel, malformations, severe fluorosis or stuff like that. Otherwise, you can handle a lot. But still, even those cases, you could handle them with composites. But there is room for both, you know?

But yes, it is true that my original book was called The Bonded Porcelain Restorations. Because at that time I have an absolutely outstanding collaboration with the best ceramist in the world. My brother and we had this amazing synergy and by the time I wrote the second book for different reasons, but one of them was the university not allowing us to work together as brothers because of the trade, basically politics there. I ended up having to do much more work by myself using composites and that’s why my second-

[Jaz]
Indirect composite. Just to-

[Pascal]
Indirect and CAD/CAM. Also CAD/CAM composite. And I guess our research group was one of the first to really go deep into the investigation of CAD/CAM composites when CAD/CAM composites were still used, were still called composites. Nowadays, companies call them hybrid ceramics and nano ceramics and this and that. And they are still fighting the stigma of what you said, which is composite is not biomimetic composite is a very poor brother in the field of restorative dentistry, ceramic is the normal-

[Jaz]
A poor man ceramic as they say, a poor man ceramics.

[Pascal]
And now what do you see? You see that here, I think the definition of ceramics was upgraded. Like you will not believe that. I don’t know if you’re aware, but anything that has more than 51% in content of ceramics can be called a ceramic, which means all are composites. According to this new definition.

And I believe it’s the even for the coding, because the company is what they wanted. They wanted insurance to pay for a composite crowns especially now that we have printed composites. Right? So the goal is to have those composite crowns being covered by insurance. And so just put 51 plus something percent ceramic content.

I believe it’s in weight. I believe it’s in weight which is even worse because the volume would be even less. And volume would be 40 something and, and then you have a ceramics. And so the thing is, this is important. I’m glad you raised that question. You know what happened in the eighties?

In the eighties, a few companies wanted dental technicians to use composite resins. And in order to make those laboratory materials, companies, thought technicians are used to take a brush and ceramics in form of the very fluid paste and put on the teeth. And so they said, we are going to make the composite feel like that, which is a flowable.

So they made flowables and you were maybe not born in those days, but there were a few materials that were complete disaster. One of them was called Targis and Vectris by Ivoclar. It was a fiber in force framework covered with flowable composite. There was a material called SINFONY by 3M.

There was different material. They were designed to feel like porcelain, but they were flowable composites with less filler, more diluent in the resin, which is more shrinkage, less wear resistance, et cetera. And so these created and influenced all the data, clinical data, especially produced about composites made in the lab because those materials behaved really badly.

The flowable composites are not designed to be definitive restoration, so they ended up hurting the scientific pool of data about laboratory made composites. Nowadays, composites are back in form of CAD/CAM material, which is much, much better. Of course, now they are highly filled, viscous, because they are made in the factory, they can be heat cured under pressure.

So they are really better. And so this revival took time when 3M came with the first composite block, which is part of the material we studied for the occlusal veneer studies. And we had amazing result. Jaz, you will not believe the composite, those ultrathin Z 100, it was called Paradigm Z 100. The name of the block was the first composite block.

They had no commercial success. 3M was actually not even selling the material in Europe, I think only in the US. And this paradigm, Z 100 composite never made it really as a commercial success, but we studied it a lot. Dr. Kunzelmann in Germany studied it a lot, and the results were amazing because it’s a spheroidal zirconia filler nano hybrid.

Well, back then we called it micro hybrid spheroidal, but very rare resistant, strong, amazing. But guess what? The stigma of the eighties about composites did not make this material kind of make the cut. And so the manufacturers decided to switch, approach and call those material ceramics. And the first really of its class was Lava Ultimate because remember what material from 3M is called lava. Lava Zirconia. 3M had a zirconia material, I don’t know if they still have it to us, called Lava, and they used the name Lava for the composite resin, which is basically a new formulation for Filtek material that they came up, you know, during the nineties and they called it Lava Ultimate, the Composite, but they called it resin Nano Ceramics.

So they tried hard. Now we have a new problem, and the new problem is the printed materials. Because the printed materials have low filler content, they have barely above 50% so that those material can be sold as a crown material and reimbursed by insurance, but they are not as good as the CAD/CAM materials, and this is going to hurt until we have highly filled printable material. And there’s a first step that’s been taken by sprint tray with a new system called Midas. I don’t know how you call it, in the UK which has 70% of filler content, so that’s good. It’s not yet as good as CAD/CAM composites, but it’s a first step and we hope that it keeps developing like that.

But meanwhile, I’m afraid that a lot of dentists are going to use printed material as a definitive restorative material for inlays, onlays crowns, and it is not going to go very well because of the properties of those materials. Personally, I promote printing and for mockups and provisionals, and things like that, which is amazing when you do full mouth rehabilitation, when you have to open the bite deprogram the patient printing those onlays and mockups is amazing. That’s the best use you can do of, of it. Okay. So-

[Jaz]
You talked about wear and that’s what went into the composite and you spoke very highly of the fact that that’s where the volumetric sort of wear is less with composite. And then we mentioned that, you gave this history about why composite has a bad rep, but actually it shouldn’t be the case.

It sounds like if you, God forbid, tomorrow lower right, your lower right molar has an amalgam and then you needed a root canal, that your restoration of choice for your molar may be a indirect composite just Yes. Based on what you’re saying, right?

[Pascal]
Yeah, sure. Absolutely.

[Jaz]
Now, back onto occlusal, ultra thin occlusal veneers. Zirconia the elephant in the room, the wear of that when you read the data, when it’s like highly polished zirconia. It can be quite kind to the enamel.

[Pascal]
Absolutely. That’s true. So that’s one of the thing with zirconia, because of the structure and it’s so smooth, the wear is not bad at all. Okay. So, but the problem with zirconia is different. The problem with zirconia is it’s extremely difficult to adjust, and I would say it might not as predictable for bonding. So you need MDP. MDP will be highly sensitive to hydrolytic degradation, the bond. So, when you bond ceramics, we do two things.

We do etching and silane and there’s synergy in there. With zirconia, you don’t have that synergy. It’s only a chemical bond with the MDP. And so you have to use cements that have MDP, like Panavia or specific zirconia primer. You could also use CoJet and or, which doesn’t exist anymore, but like CoSil, or SilJet from Danville, and you could silicote the zirconia and then use silane.

I just wanna tell your audience here, don’t use silane on zirconia. It’ll not help. It’ll not do anything unless you silicote the zirconia by air braiding it with silicated sand like CoJet CoSil, or SilJet , et cetera. If you are not doing that, the silane is useless. The only monomer that will be useful is MDP.

It’s a phosphate monomer that’s going to covalently bonds to the zirconia, but again, that bond is susceptible to hydrolytic degradation. So you are making your life a little bit more complicated. I would like to say, when people ask me about zirconia veneers mm-hmm. What I tell them is, if you are used to take your restoration and drop it on the floor, throw it against the wall, step on it, and make those kind of things, then zirconia is perfect for you.

You have more chances to have an intact restoration to bond. But if you are careful with your restoration, you really don’t need zirconia because the strength is going to be obtained by the bonding and it’s the story, my dear friend Roberto from Italy, had this funny way of saying it.

He said, bench test versus the restoration on the tooth is like the story of the helmet and the wool cap. If you take a helmet and you drop it from the top of a bridge and you let it crash at the bottom there, it’ll break in in pieces, right? You take a wool cap, you, you drop it from the top of the bridge.

The wool cap will go down and float down, and you take the wool cap, it’s intact, right? So you would tend to see the wool cap is better. Of course, the thing is there is a head together with the hat or with the helmet, right? So a bench test means nothing. So you can have 700 mega pascal of flexural strength.

But that’s not going to help. And actually, like my mentor, Dr. Douglas was saying, those super strong material, they make the inside of the tooth become hyperfunctional. And that the stress that’s not absorbed by this part is going to go near the margin, into the deeper structure. So we are back to the discussion about the cusp if you want, right?

What is stronger, stiffer, always better. The answer is no, because something will have to give at one moment. And you want the restoration to give, not the tooth, right? And like I was telling in London, this is one of the biggest element of biomimetic dentistry is to say that the restoration should be allowed to fail in order to protect the tooth.

So zirconia is the opposite. It’s never going to fail because it’s so strong by itself, but it’s not going to necessarily protect the tooth from failing. And it’s a difficult technical material occlusion adjustment, contact adjustment.

[Jaz]
Well, the issue there is when you do an occlusal adjustment, you’re losing that highly polished, you’re now getting a rough zirconia. And then you have to impose the polish again.

[Pascal]
Exactly. And you affect the properties of the material too by doing that.

[Jaz]
And you get micro cracks-

[Pascal]
And it is very complex. And I think zirconia is really, I would consider zirconia mainly for bridge work. That’s where you have connections, but this is not biomimetics anymore when you are replacing a missing tooth.

And I have to tell you, I have huge respect for the works of Matthias Kern in Germany. Kern, who published so much about resin bonded, fixed partial dentures. And the long-term results, with simple panavia on zirconias and one cantilever pontic, and the results are fantastic, I think.

Many patients in a young age especially should be given that before an implant and look at the implant later. You see, it’s always the same principle of wisdom. Let’s do the simple stuff first. We can always make it more complicated later. And when we see with implants, the problems are long, long term.

I mean, if you place an implant in a patient in his twenties or thirties, what is going to happen after they are 50, 60? This is big because those implants don’t move. So if it’s a single implant, you can expect some possible problems and that’s why I would try to delay. I always say, if you can wait after age 40, 45 for an implant, that’s better.

[Jaz]
I totally agree. And I also vouch for, huge fan of resin bonded bridges, and especially for lower incisors. Why would anyone do an implant for lower incisor? It’s just when you have great success with resin bonded bridges. Now, back to occlusal veneers. One indication, which you kind of touched on when you mentioned about.

The printed materials being very good for those interim and mockup and provisional rest scenarios, which it makes complete sense, but also when you have the wear patient and you are opening the vertical dimension and they have maybe mostly anterior wear and then their posterior is not very worn, therefore you have that lovely enamel.

Now you open the vertical dimension and classically, what someone may do is. They may drill the cusps down to give them the correct thickness of the traditional thickness of occlusal veneers. But nowadays we can go very thin, as you’ve said, with the occlusal veneers. So you can do minimal prep or no prep. How thin can we go with either indirect composite and or ceramic?

[Pascal]
So, according to the studies with Dr. Schlichting, we went down to 0.6. Right? So those were the minimum. But then we have a manufacturing limitations, right? Less than that, it’s going to be extremely difficult to have clean margins.

And so my question to you would be, when you are getting that thin and the teeth are in good shape, you just use the DAHL principle, you don’t restore them, you know? So in your side of the world, this is actually very well known, right? It’s much less popular here in the us. Still a number of dentists who never heard the name DAHL here.

[Jaz]
And many lecturers in the US who really frown upon it, they see DAHL as a very sloppy orthodontics. They see it as a sloppy way whereas we love it here. We are big proponents of it. And same as Scandinavia, you know?

[Pascal]
Absolutely. Yeah. So to me, for localized anterior bio corrosion and wear, there’s no doubt that DAHL is my go-to most of the time. If posterior teeth do not show any signs of suffering and corrosion or wear, you let them come back together. And I always say, I don’t do DAHL, I do micro DAHL or sometime even nano DAHL, because when you look at the original studies in the seventies from DAHL, they were opening those bites enormously and the patient were hold open with fixed metal appliance, like resin bonded bridges type and they were the posterior teeth were left to extrude like millimeters, literally. I do like tens of millionaires of passive, eruption and that goes very fast. It’s a few weeks, a few month at most.

And that allows you to just open like a lingual space to place, or direct composites if you have just the notches. Sometime you have those tight, I call those the tight bites, right? So you get free of a tight bite by opening the bite or, and deprogramming. Then you place the composite there to hold the bite open while the DAHL principle is happening in the back.

To me, this is the most, the best kept secret in full mouth rehabilitation. And if you deprogram, you open the front, there’s a gap in the back. You look at this gap, if it’s a big gap, you can restore or you can still do DAHL if it’s a small gap, you can do DAHL or small, tiny direct composites.

So I’ve done low cost, full month rehabilitation with that technique which is amazing. And so localized anterior wear bio corrosion. That’s my go-to approach. Now when it’s generalized, now you have to look at the anterior relationship because some cases. So if you have a ideal, when you have generalized wear, bio corrosion, very severe, generalized, you might end up in a class three situation, right?

Because when you lose height quickly as you can imagine, a class one becomes a class three by the movement of the mandible, right? So these cases are very easy. You just open them, you recreate anterior, overjet and you restore it. When you have a class two, in those cases, that’s when you have to be a little bit more careful because if you deprogram you make the class two worse.

And so some of this case might be really indicated to open the by without the programming so you don’t make anterior relationships worse. And so that’s why you have to be careful with those cases. But when there is major damage in the posterior, those are perfect indications for occlusal veneers, and as you asked me, yes, we can go down to 0.6.

[Jaz]
So yeah, 0.6. But, so here’s my new knowledge for me. So my understanding is 0.6 on enamel, but in that scenario of the generalized worn dentition, let’s say there is a dentine exposure posteriorly, are we still comfortable in having 0.6 millimeters of composite or ceramic on the dentine, which behaves differently to enamel?

[Pascal]
Exactly, and that was the situation. By the way, in the studies we made with Dr. Schlichting, we always exposed the dentine completely occlusally. We were only with a rim of enamel, but the dentine was completely exposed. So guess what I’m going to tell you about this question. My answer will be if you do immediate dentine sealing, and I’m going to be totally clear on that, if you do IDS correctly with the right product, and my golden standard is OptiBond FL for many, many different reasons.

If you do IDS correctly with Optibond FL, we find that basically. You are like an enamel. And so that parameter disappears for me. When you handle dentine bonding correctly, which is with immediate dentine sealing, you are in a full enamel situation and we can see dentine basically disappeared.

The moment you do ideas correctly, dentine disappears. You are in an enamel only situation. Patient will not have sensitivity anymore, and you can bond your onlay as you would do if the preparation was only in enamel. That means you clean this prep by air abrasion. Etch. You can etch the entire surface.

Etching is not going to affect the IDS layer and then apply fresh adhesive and your luting composite. And by the way, Jaz, you see that’s another thing when we are talking about those thicknesses. In our studies, not only we used IDS, but we bonded those thin onlays with a highly filled restorative material.

We used a restorative composite as a looting agent and you can find those articles with Dr. Gresnigt that we co-published where we looked at the strength of thin Emax veneers, anterior veneers. Not posterior veneers, but Emax on full dentine preparations. And if you do IDS and you bonded them with a highly filled restorative, that will be really a difference compared to bonding them with RelyX veneer or, Variolink Esthetic or things like that, which as I told you, they are not as strong because they are flowable.

For a material to flow, you have to pay a cost, which is the filler content or the quality of your resin matrix. So those highly filled materials, we preheat them. And we use them as cement.

[Jaz]
And can you give an example of which composite to use? ‘Cause there’s different thicknesses and you can’t get the thinness enough.

[Pascal]
Yes. Not all those composites are created equal. And the problem today is because of the nanotechnology. The nano fillers by themself make composites very viscous. And in order to fight that problem, manufacturers have to include pre polymerized filler complexes in the material. Those are bigger chunk of composites of it’s pre polymerized filler.

It’s made of the same filler, but it’s pre polymerized ground and included to decrease the viscosity of those highly filled nano hybrid. Those pre polymerized fillers can be very big up to 20, 30 micron. Those material will never work as a cement because those chunks are too big, right? So you have to use more traditional micro field.

And in a recent article in the Journal of Aesthetic and Restorative Dentistry, we published like tests about what material will do a decent thickness, film thickness. And amongst those you have Gradia Direct, you have Transcend by Ultradent, you have Filtek Z2 50. Very surprising. You have APX by Kuraray.

You have ENA HRi by Micerium and there’s a bunch of product. But also we notice that some material may become more viscous when you hit them too long and some product for. Unknown reasons to me have heat initiators, and one of them is APX. APX will work as long as you don’t hit more than five, 10 minutes.

I would say maximum. After that, it’ll start to become more viscous and it seems it’s because of the present of a heat initiator, which I don’t understand to why there would be a heat initiator.

[Jaz]
I mean, you’ve covered so much and so thank you so much and it’s really nice to hear about indirect composite and these views about it being a second rate material, it really needs to change with the data that we have at the moment.

So with that in mind now, could you just describe for our listeners, the step-by-step protocol of the thin occlusal veneer comes back, which is, let’s say a CAD/CAM composite, the try in and the risk of it, let’s say breaking, doing try-in, checking the occlusion. Should we check, should we not check? And then the actual steps to bond that in as our final question.

[Pascal]
Yeah, so you always have to keep into account the fact that when you try the restoration, are you going to try just the fit or are you going to test the occlusion? So we did some publications about that. And of course there is always a risk of breaking the restoration if you let the patient bite.

So with thin ceramics, it’s a little bit more tricky than with thin composites because composites, again, has this flexibility that the ceramic doesn’t have. So you wanna be extremely careful when you do these tests. One thing that will help you a lot is immediate dentine sealing. And do you know why?

[Jaz]
No. Go for it.

[Pascal]
Because when you do IDS, the patient doesn’t have sensitivity anymore. The dentine is sealed is desensitized. So you can test your restoration without anesthesia. And if the patient is not anesthetized, as you know very well, the proprioceptive response is much higher. They will less likely bite strong when you test the occlusion.

So, IDS will actually be the most important element. You don’t need to anesthetize and your patient is much, much more sensitive to the occlusion and to the biting, and you have less risk of breaking that restoration during the try in. So that’s important. But in general, the beauty is with composite resin, if the bite is a little bit off, it’s so much easier to adjust than with lithium disilicate, or even worse with zirconia. So it’s not going to be that of a big deal. If it’s a little bit off with composites, it’s going to be a little bit more complicated with ceramic, with zirconia because then you have to repolish and repolishing in the mouth is a little bit more labor intensive for those ceramic materials.

So in general, I would say yes if it’s an onlay as we talk, if you look at our studies, you will see that.

Interjection:
Hi friends. Just interjecting here. One thing I asked Dr. Pascal Magne, there was an error with a video is, is there a difference in trying in composite versus trying in ceramic? And does it matter if it’s an inlay or an onlay?

If you take inlays trying in the mouth, a ceramic inlay is a safer bet than trying in a composite inlay, you’re more likely to break the composite inlay than the ceramic inlay when you’re trying it in. Of course, you have to be careful in either scenario. Now, when it comes to the onlay, interestingly, you’re more likely to fracture the ceramic onlay and the composite onlay is a safer restoration to try in with the occlusion. Why? Because it has more give, more flex. Back to the episode

[Pascal]
Because it’s an extra coronal strengthening inlays will very likely break at the isthmus between the box and the occlusal surface, especially when you have a very strong, a narrow isthmus like that between the box and the rest of the occlusal.

If you have a little high marginal ridge there, that’s when you have the like the most risk of breaking it. So you have to be careful. But here my answer is immediate dentine sealing will give your patient much more sensitivity and then composite resin will be much more forgivable when you do those triads.

[Jaz]
And so rubber dam and just, are you gonna air abrade the intaglio of your CAD/CAM composite?

[Pascal]
Yes. So CAD/CAM composites, they need to be treated like an aged composite. Basically when you repair composites, you have, if you repair a composite that you did recently, you just air abrade leave it wet with adhesive resin. If it’s a composite that’s been in the mouth for six months a year, then you have to air abrade with CoJet, silanate and add adhesive resin.

So those materials, CAD/CAM materials, because they’re highly polymerized, you have to treat them like a repair. So what I like to do is to air abrade them, I would preferably use CoJet. You can use aluminum oxide, but I will preferably use CoJet to maximize the effect of the silane.

And then you use the silane and the silane you have to be careful because this is where there’s a lot of misuse of the silane. The silane has to be placed for no longer than 30 seconds wet and then air dry. You never let the silane dry by itself. You have to air dry and heat dry the silane because when the silane reacts with the filler in those composites, it’s going to develop equivalent bonding and one molecule of water is going to come out of this reaction. It’s called a condensation reaction, and that water has to be evaporated along with the alcohol, which is the solvent used in the silent solution. So the hot air is going to make a big difference in the reactivity of the silent, in the covalent bonding, and the hot air is going also to increase the inter layer cohesiveness when you have too much silane on the tooth, which is almost unavoidable. The silane, ideally you would like one layer, one monolayer with each molecule aligned like a little soldier with the hydrophilic part against the restoration, the hydrophobic part against the adhesive resin.

But you have more than one molecule. They are stacking on each other and the use of the heat will increase the cohesiveness between those layers of excess silane. But when you leave the silane in excess dry by itself for 60 seconds, for instance, then you create a huge excess of silane. And then more excess means more problems with the cohesiveness of those layer.

The good use is when you heat dry, the silane, you increase the cohesiveness between those layers. You improve the performance of your silane by two times according to an old study by my dear friend and colleague, Jean-François Roulet. So the heat drying of the silane is very important. And then when you use preheated restorative material, it’s very important to wet the restoration with adhesive resin.

For my part, I use the second bottle of OptiBond FL. So the tooth is air abraded and etched resin coated with OptiBond FL bottle number two. Unless you notice that you have missed some dentine, in that case, I would apply the primer. But if there is no dentine exposed because you did such a good IDS, you don’t need the primer.

The second time. So etch, air abrade etch, rinse, dry, apply adhesive resin, no polymerization you don’t need. And then on the restoration you do your air abrasion. Preferably with CoJet you can use aluminum oxide, 30 micron, at low pressure, and then CoJet if possible. And then you apply the silane for 30 seconds.

Air dry, heat dry for one minute, and then adhesive resin unpolymerized. And then you use the preheated composite as a cement. That’s how we did in our study where those occlusal veneers were unable to fail if you want, because of the extreme strength of the bone. In the other study about the non-vital teeth with the thicker onlays, what was really amazing is IDS was so efficient that when those onlay broke, the fracture went from the restoration into the tooth straight.

There was no failure of the bone. And we took the teeth. Actually, when I said none of the teeth survived, it was wrong. With the composite resin onlays, like, which was Paradigm Z100, we had a number of teeth survive. And when we took those teeth that survived our very demanding occlusal pounding after the test, and we measured the dentine bond strength, the value was still as it was originally in the unfatigued teeth, which is about 57 to 58 megapascal. Remember, the dentine enamel bond strength, biological bone strength is around 50, 51 Megapascal. So, I’m not telling you we are better than God, but when the bond is so good, the higher the bond, the less it’ll degradate.

So you wanna start higher than the dentine enamel junction because it is going to go down. It is going to go down. It’s unavoidable, but the rate of degradation will be less when your original number is very high. If you start at 58, maybe one year later you lost, maybe at worst 10%, but when you start at 35, 1 year later, you lost at least 30%.

And that’s one of the study by Van Meerbeek demonstrated the meta analytical review of all the adhesives studied on the market. It was about 10 years ago. Number one was OptiBond FL, number two was SE bond with the- Also not only the highest bond strength, but the best stability of the bond.

[Jaz]
Amazing. Well, I’m gonna summarize this episode in four sentences. Number one, above everything preserved tooth structure ’cause that is the biomimetic way. Number two, good quality bonding protocol will allow you to do that and allow you to be a biomimetic. Number three, the importance of IDS and doing that well and how imperative that is for these protocols.

And number four, the use of indirect composites for, in all these scenarios, especially for root filled teeth. Thank you so much Dr. Magne, for spending the time with me. It has been a dream to bring you on the podcast. That dream has now been realized and that honestly, I’m so, so happy to know you and to have this opportunity. Please, can you tell us about the upcoming courses at Magne Education? I know you have so much going on. We’d love to know.

[Pascal]
Yeah, yeah, absolutely. Thank you for this opportunity. And yes, so, we are trying to serve everybody with our courses because I know that for some people they are more local. They travel easier. Some countries it’s really difficult to travel, get visa and travel organization can be a nightmare. So we have online programs for that. It’s called Press Room, and we offer Press Room the two most common language in this world. Well, actually I’m wrong. I should learn Chinese maybe, but it’s English and Spanish.

So we have Press Room once a month. It’s a program of 10 sessions, 10 month, and we cover really the essentials of biomimetic restorative dentistry. We have like usually 70 minutes, 75 minutes of presentation, and then we have question answers for at least 20 minutes. So it’s really nice, it’s interactive and if you miss the day of the live.

You can watch it recorded inside our intranet platform. We have a great, by the way, website. We spend a lot of energy on this website, which is the intranet, the portal. And in the portal we have forum discussions and stuff for each course. It’s really nice. So then if you wanna visit us, we have our hands-on courses and one of our flagship courses called The Continuum.

This is our mini residency, five time, three days, and we again cover from aesthetics and morphology all the way to the advanced bonding technique and veneers. And then we have what we call summer school. So we have, usually we do two semesters of those continuum courses, and then we have summer school in between, which is extra courses.

And in those extra courses, we talk more about customizing your CAD/CAM restoration. For instance, you have a chairside CAD/CAM system and you wanna mill your veneers and you wanna be able to maybe even customize your Emax by yourself. So with a little cutback and micro layering. So this, we teach in a course called CADPlus.

And then we have our extra wear course, which is full mouth rehabilitation of the worn bio corroded dentitions, using, again, occlusal increase of the vertical dimension and stuff like that. And how to sequence and your treatment plan in a way that’s going to be very easy, very common sense using printed mockups or analog mockups.

I still love analog, but we wanna be surfing the wave of technology. And now with printing, it’s amazing. I’m a huge fan of exo cad. I am learning exo CAD very fast because I think it’s an amazing tool for digital approach. And so we will teach exo cad printing and full mouth rehabilitation. This is CAD, where it’s a three day course and we have other stuff that-

[Jaz]
That’s the one I wanna come to the most.

[Pascal]
Information is available on magneeducation.com and Jaz, you did it yourself. One of my favorite thing is what we call mentoring. And, you can book with me, one-on-one time like we are doing now if you want. And that’s called the mentoring program. It’s also available.

[Jaz]
I will put the links to that, including Magne education in the show notes. So it’s easy for you guys to find. I highly condone it. I mean, everything, every time I’ve seen you speak, you just come back energized Edinburgh, London. And I really want to come to your full rehab course one day, especially as I’m not doing many of these printed restorations. I’m new to that area, so much to learn. So I’ll put all those links and I just wanna say thank you so much for everything you do.

[Pascal]
Thank you.

[Jaz]
With the knowledge to this world. Thank you.

[Pascal]
Thank you, Jaz. It’s been a great pleasure and God bless you and the Protrusive podcast. We love you.

[Jaz]
Thank you so much. Well, there we have it guys. Pascal Magne, it happened and it was awesome and I’m really hoping you enjoyed it. Loads of gems in there. Look, this is one of those episodes where you need the premium notes, our premium subscribers can access the PDF transcript and the premium notes where we kind of summarize everything in an easy to digest way. And what that serves to be is like a rocket for your learning. Like I know you pick so much up from this episode, but why not increase that retention of information to allow you to apply those techniques to harness the power of the knowledge?

And that’s where our premium notes absolutely shine. Check out one of our paid plans if you’re interested in that. And the way to access it is www.protrusive.App. Now, top tip visit on your browser, ’cause that’s how you can access the one week free trial and the best price. Once you’ve made your login, you can then download our Android or iOS app and then use your newly made login credentials.

If you’re not already on there, it’d be great to have you in the nicest and geekiest community of dentists in the world. And another one of our mottoes is Fall in Love with dentistry. Again, it’s easy when you’ve been practicing for many years to eventually get disengaged with work. And what I want my legacy to be with Protrusive Guidance is to allow you to engage with your geeky side, allow you to enjoy your dentistry, allow you to be scientific and proper about your dentistry, whilst having fun and satisfaction knowing that you are doing the best for your patients.

You’ll also get access to the Protrusive Vault where I’ll put all the papers that Dr. Pascal mania mentioned. I mean, what a guy, please check out all his educational stuff. I’ll put those links to his courses below. So scroll down and you’ll see them. And thanks so much once again for listening to the end.

I’ll catch you same time, same place next week. Bye for now.

335 episodes

#Science #Medicine #Fitness #Podcasting Education #Self-Improvement #Jaz Gulati