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Well, welcome to episode seven.
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We have some information that you're all going to find very interesting and very practical.
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And it's a follow up on episode six where we talked about the stress reduced approach that Simone Deliperi first published in 2002, and we wrote some articles 2009, other articles that we've written.
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But the stress reduced direct technique is a part of every biomimetic restoration.
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Whether you construct the whole tooth as Simone does often, or you take the foundation and stress, reduce it for your bio base, the stress reduced direct technique is part of that.
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Now we're going to talk about the other stress reducing technique in a bio base that is critical besides the composite incremental technique that Simone published.
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And this is called deep margin elevation.
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Now a deep margin elevation is a stress reducing technique.
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Why is that?
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It's because these deep areas have to be built up separately from the rest of the missing dentin.
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And that separate build up takes time and so on.
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We have a deep margin elevation.
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It's taking time.
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In that time allows the bond to the dentin, the time to mature and to time to flow towards the hybrid layer and that maturation is what we call decoupling with time.
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So stress reducing direct technique for mobile base that includes deep margin elevation.
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These are protocols that allow us to have the highest bond strength in our getting replacement.
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So the articles that we will be talking about today will be 1998 Didier Dietschi Roberto Sprefico, the first published illustration of a deep margin elevation.
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After that, two other papers from Dietschi that followed up in his Ph.D.
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research.
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And those two papers investigated what kind of materials should be used for the deep margin elevation.
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And that was published in 2003.
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Also, in 2003, we had a paper that showed that a separation of the deepest part of a class to should be separated by time to have the best results in a class two restoration.
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So a deep box and a class two restoration are very similar, except ones deep ones not as deep, but both were shown by Dietschi to have a benefit with these stress reducing protocols.
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And then we have independent confirmation from three countries actually, when they talk about the deep margin elevation 2012, Pascal Magne and Roberto Spreafico specifically published that article.
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And then in 2014, a German group did the same long term in vivo study in vitro and in vivo studies compared.
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And then in 2019 we had a long term 12 year study from David Gerdole and his associates in France and in Holland, particularly Marco Gresnigt in following these deep margin elevations.
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Long term.
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So let's talk about how did I first do my first deep margin elevation?
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Well, it has the history in that with traditional dentistry, I was doing a lot of root canals.
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And so with root canals that had been caused from leakage and decay around deep class two restorations, I had the opportunity to learn how to be a better and at honest, and I took advantage of that and that was from courses given by my class valedictorian at University Pacific, Steve Buchanan.
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Steve Buchanan had revolutionized the anatomic world when he started to embrace mechanical rotary instruments, nickel titanium files, and he became very popular speaker.
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And I went to many of his lectures at ADA convention, and then I did a hands on course with him and that hands on courses in 1999.
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And that was the first time I was introduced to a microscope.
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And then I bought my microscope at the end of that year.
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But then in these times when I was becoming a very proficient endodontist, I would do my own endo.
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And then after I had done that, then I would restore the tooth.
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But the situation in endodontics is that you must isolate the tooth to prevent bleach, which is the irrigating solution from going into the patient's mouth, which is never a good if the patient is having the bleach put into there into their oral cavity.
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So what I'm doing my endo, if I have a deep sub marginal defect that I'm trying to isolate, that's a problem.
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Traditional techniques would say, well, you could go and do a crown lengthening surgery.
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I knew how to do that and I could do that.
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But then there's a healing time.
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But the idea came to me when I was getting ready to do a molar and at our treatment that if I built up the deep sub gingival wall with composite, which had been, you know, started training two years before with Ray Bertolotti.
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then I could isolate the tooth with the rubber dam easily and there would not be a problem with bleach contamination.
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So I did my first deep margin elevation, 1998, early 1998, and I did it with the chemical cure materials that I had chemical your bonding system, photo bond and the dual cure material that it was called the best field to be made by Ray Bertolotti from Biscoe.
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And this technique that I use to elevate this margin once it was bonded, allowed me to isolate and do my ended on a treatment, but then my ended on a treatment was done.
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And I'm looking at this bonded box that I had full confidence in, even though in 1998 I didn't have all the details of hierarchy of Bondability and dental flow with chemical cure composites that we talked about last episode.
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But I did know that the C factor was very low why?
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because I actually could see the bonded surface is just the shell of the box bonded on two thin sides of the mesial and buccal and one box depth.
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But then the on bonded surface of that wall that was being built to isolate tooth that had a huge unbonded ratio.
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It was very, very low.
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Therefore the shrinkage of the composite would not stress the bond very much.
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It would shrink not away from a wall, but towards the center of mass.
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You know, the I could make an illustration of that.
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It's a little bit complicated if you haven't been trained in the six lessons.
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But still, the idea is that I elevated a deep margin 3 to 4 millimeters with chemical pure composite.
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I used a dual cure bonding system photo bond, and then once I had that done, allowed me to do the handle.
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And then the question was traditional techniques.
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In 1998, I'm still going between crowns.
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No crowns, crowns, no crowns.
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So I felt comfortable in large composite.
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Obviously I've been doing crowns successfully for 18 years, but I looked at their restoration and I'm saying I'm not going to take that off so that I can create a perfect ferrule A ferrule by definition is two millimeters of sound to structure that is going to give the firm foundation that the Crown is going to attach to, but that ferrule was going to be two millimeters sub gingival.
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And so I had to deal with the gingiva, which would be a surgical procedure or if I have the bonded deep margin and it sealed and I'm not relying on mechanical retention which a Farrell is part of in a Crown retention, but I'm just going to be relying on adhesive compliant planning in this situation to do a large inlay actually.
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And so at that point I said, look, the rest of my tooth, the bond to dentin has been established was actually established 24 hours ago.
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I had finished the Endo patient came back actually the next day and I had this bonded surface and I said, I'm just going to add to that surface.
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So the immediate dentin sealing is in place.
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There's been no stress on the dentin bond of all of the dental surface around the root canal, access to the pulp chamber.
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I didn't edge, but I knew that the composite, the immediate end ceiling should be cleaned a little bit.
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And so that surface was rinse dried that point.
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I'm not sure if I had air abrasion, but I added another layer of adhesive on to my immediate and ceiling.
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And then I looked at my preparation that was immediate and sealed and then the deep margin was elevated in the back.
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And then I said, Well, there's some undercuts here.
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I can change the geometry by taking out those undercuts by adding composite bonded composite.
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So I changed the geometry of the large inlay shape preparation by one doing the deep margin elevation separately and then removing any undercuts by an additive technique.
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And all of a sudden I had a nice, smooth and flat on the bottom and smooth on the side inlay preparation that had composite on the gingival floor that it had been elevated and then composite on the buckle and lingual walls.
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And I had now a nice inlay preparation that had draw and I took that impression and made my inlay my large inlay.
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And then cemented it with protocols of a resin cement.
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And after that was done in 1998, I looked at it and I said, Well, I wonder if anybody else in the world is doing this.
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And, you know, I was determined to find out.
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So 1998, I went to the ADA convention and May, had lunch with Bortolotti and met Gary Unterbrink for the first time and heard John Cank and Charlie Cox heard the name John Kois.
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I mean, 1998 was that year for me.
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That really got me into a commitment of learning as much as I can about adhesive dentistry.
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But in 1998, the published book from Dietschi was this book, and I purchased that at the convention 1998.
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It did not have deep margin elevation in that book, but I had the opportunity to talk with Gary Unterbrink, talk with Ray Bertolotti.
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They didn't see any any problem with having a resin base underneath the composite restorations, just making it larger.
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But the separation of these two masses of composite the inlay and the resonance base to me was now becoming clear that the key factor determined portion of my deep marginal elevation that I had made was the correct one.
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Again, I didn't have decoupling with time and hierarchy bondability in 1998 fully in my mind.
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But as I saw this restoration go on for the next few years, I visited Didier Dietschi as I took a course two day course at UCLA in the year 2000.
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I wanted to see if he had figured out this deep margin situation he had, but he had not figured out the hierarchy of bond ability and the decoupling with time.
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But still we talked about marginally elevated.
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Yeah, I just published a paper coming out this year and that paper will show that for the first time and this is the paper and it's a paper that the title had nothing to do with.
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The marginalization says current clinical concepts for adhesive segmentation of tooth colored posterior restorations is the first time that heated composite is used to see these inlays launches.
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But in that article there was a very small illustration, and this small illustration had immediate debt and ceiling and a deep margin elevation, not a very deep one, but it was definitely a situation where the bio base is created first by a base that was wasn't named until 2003.
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It's now in Magne Belser’s book, but Wendell Robertson came up with the bio based term, I have popularized it.
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But that paper in 98 was part of Dietcshi’s investigation that he was carrying on, and eventually he got a Ph.D.
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dissertation, and that dissertation publication contained two articles that had been published in a kind of an obscure journal for Americans, European Journal of Oral Sciences, but that these two papers gave the information that the composite should be used for this deep margin elevation.
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Composite had characteristics that were more tooth like didn't use the term biometric, but that's what he meant.
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And then as the years went on, I came to in 2005 to visit Pascal Magne to see what he knew and see what he was doing and what his plans were.
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Because I've been teaching the six lessons for two years and the first case that I showed him was that the deep margin elevation that I did in 1998, so this is at USC in 2005, this restoration is now seven years old.
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And I showed it to Pascal and he said, Nobody's published that yet.
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And I said, I know.
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I've been looking at the literature and talk with Dietschi He hasn't published the case, but he had an illustration that he said was going to be in the new article.
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And at 2005 then I did have access to that article.
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But anyway, the idea was that in Geneva they were doing this.
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I had been doing this my office, 1998 was the year that we both figured this out independently.
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We fast forward as we keep practicing dentistry and doing dentistry, and I'm teaching dentistry now to dentists, practicing dentists in 2003 and the dissertation from Dietschi is published, I get a copy of it from Pascal.
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He had a copy in his office.
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I borrowed it and made a copy of actually made three copies, gave one to Simone Deliperi and that Ph.D.
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dissertation is an outstanding piece of work.
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I thanked Dietschi for this.
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Last year.
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When I spoke with him, Davey and I were on the same stage, the same conference in Chile, but you know, working these concepts out until it becomes taught and then practiced and then monitored long term, that's a more difficult thing to do.
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The first paper published by Pascal Magne and Roberto Spreafico, he actually said that this deep margin elevation was a paradigm shift.
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Obviously, it's something that, you know, bonding or restoration to a composite base, people that don't know composite chemistry and don't know the the difficulties of it and are very afraid to do that.
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But to those of us who became masses of adhesive dentistry early on, we understood that this had the ability to connect with the two side to side front.
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The back and top the bottom in that 30 plus megapascal range.
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And this has been proven that's science.
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But then to get enough people to do it and follow it, there's two important papers that were published, the one out of Germany and the title was Proximal Black Box Elevation with resin Composite and the dogma of biologic width clinical are two technique and critical review.
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They called it the R two technique.
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They should have called it the deep margin elevation two years before Magne Spreafico were the first ones to put that term in to publication.
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There had been a USC manual in 2006 that included that.
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But you know, that's kind of splitting hairs.
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But the Germans, what they wanted to investigate is why these sub gingival composites were not bleeding because the myth or the dogma of biologic with the violation that every periodontist and president is working in, in conjunction felt like it was a reaction of the tissue to the Crown material where in reality it was a reaction to the biofilm underneath the crowns that were not bonded and did not stop this gap formation underneath crowns and fillings.
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So inflammation of gingival of an amalgam or inflammation of gingival of a composite or inflammation of gingival of a crown is actually related not to the material but to the bacteria that are underneath the crown or the filling.
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And so that's what causes the inflammation.
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If you stay bonded in these deep margin elevations, then that inflammation goes away.
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This paper by Bresser and Gerdolle, Heijkant, Pouwel, Cune and Marco Gresnigt my good friend at Groingen University in Holland, their papers showed 95% no inflammation on any of these deep marginal nations.
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Some of these been followed 12 years published in 2019.
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And so my cases are more than 20 years old and the same situation is they stay bonded.
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There's no inflammation, there's no biofilm underneath the crown or the restoration.
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And so the biologic reaction, the inflammatory reaction of the gingiva to these bacteria is what's called what causes this inflammation.
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And often associated with bleeding, as the inflammation is into the connective tissue portion of the gingival attachment.
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Wow. So that's how deep marginalization has got going.
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And they're possible with composite.
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They're not possible long term with resin modify, glass, monomers and glass enemas.
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It's a little discouraging when I hear training that some of the top dental schools where they're actually still doing deep marginalization with glass eye armor, that's also called an open sandwich technique.
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That technique was thoroughly debunked in the late eighties because the glass monomers were brittle under functional stresses they would break down in the years 4 to 6, there are no 20 year deep margin elevations using glass.
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I honor the successful cases, but it's still being taught in the couple of dental schools around which it wasn't being taught it.
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It'll be good for four or five years, but then you have to redo it because it breaks down underneath your composite only in layer restoration.
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And that comes from solid science.
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The Ph.D. work of Dietschi.
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Consider him one of my early mentors, of course, Ray Bertolotti and Gray Unterbrink.
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Didier Dietschi I was very impressed with everything that he was doing as far as minimally invasive and adhesive dentistry.
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Of course, esthetically just totally beautiful, and after the course it was actually under the direction of Ed McLaren at UCLA.
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He was teaching a cosmetic dentistry master course at UCLA at that time.
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But the and Ed McLaren and I were talking, I said, I think you're the best dentist the world, but who do you think is the best dentist?
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And he without hardly even thinking, said Urs Belser, because I hadn't heard his name.
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I had read it, but not remembered it.
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You wrote part of the introduction to Dietschi’s Book, and Urs Belser was the mentor of Didier Dietschi and the mentor of Pascal Magne.
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And Belser was is a president who mastered all areas of prosthodontics and all areas of implant dentistry associated with prosthodontics and Belser’s a top researcher, teacher, the administrator, just a great human being from all reports.
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I haven't met him personally, but Belser basically told Dietschi if adhesive dentistry lives up to his potential, it will eliminate most of the endo.
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It will eliminate most of the perio, it will eliminate prosthodontic destruction of tooth structure.
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And so all of the specialty disciplines, including implants, will be majorly impacted by implementing adhesive dentistry.
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Now, if you're a specialist, you might not like to hear that message.
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I know when I told Steve Buchanan about the six lessons 21 years ago, he had lunch.
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I said, Steve, this is going to prevent a lot of endo.
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And he looked at his says, Great, He's very busy in Santa Barbara.
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Still is.
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He's still teaching and practicing, I believe in Santa Barbara, but he changed the world of endodontics The world paradigm has changed.
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Unfortunately, it's mostly based on extracting teeth that could be saved with the periodontal treatments and good restorative treatments like biomimetic dentistry.
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But these evolutions Belser was for he felt like it was progress.
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As long as we're conserving to structure and conserving pulp tissue, Belser understood the difference between a vital and a non vital tooth and all of the investigations since the early 2000s of reinforce the idea that a brittleness comes from antibiotic treatment that cannot be remedied.
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A tooth that has entered our treatment has three times the potential to fracture because it's three times as brittle and it's only a third of the engineering term as toughness.
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So a tough tooth, tough material flexes a brittle tooth.
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Their brittle material begins to fracture through crack initiation, crack propagation, and finally catastrophic failure.
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Anyway, the lot to think about.
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But here we are change the world.
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They'll next time get bonded. They bonded.
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Well, welcome to episode seven.
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We have some information that you're all going to find very interesting and very practical.
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And it's a follow up on episode six where we talked about the stress reduced approach that Simone Deliperi first published in 2002, and we wrote some articles 2009, other articles that we've written.
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But the stress reduced direct technique is a part of every biomimetic restoration.
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Whether you construct the whole tooth as Simone does often, or you take the foundation and stress, reduce it for your bio base, the stress reduced direct technique is part of that.
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Now we're going to talk about the other stress reducing technique in a bio base that is critical besides the composite incremental technique that Simone published.
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And this is called deep margin elevation.
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Now a deep margin elevation is a stress reducing technique.
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Why is that?
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It's because these deep areas have to be built up separately from the rest of the missing dentin.
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And that separate build up takes time and so on.
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We have a deep margin elevation.
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It's taking time.
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In that time allows the bond to the dentin, the time to mature and to time to flow towards the hybrid layer and that maturation is what we call decoupling with time.
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So stress reducing direct technique for mobile base that includes deep margin elevation.
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These are protocols that allow us to have the highest bond strength in our getting replacement.
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So the articles that we will be talking about today will be 1998 Didier Dietschi Roberto Sprefico, the first published illustration of a deep margin elevation.
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After that, two other papers from Dietschi that followed up in his Ph.D.
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research.
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And those two papers investigated what kind of materials should be used for the deep margin elevation.
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And that was published in 2003.
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Also, in 2003, we had a paper that showed that a separation of the deepest part of a class to should be separated by time to have the best results in a class two restoration.
00:03:17.079 --> 00:03:33.329
So a deep box and a class two restoration are very similar, except ones deep ones not as deep, but both were shown by Dietschi to have a benefit with these stress reducing protocols.
00:03:33.430 --> 00:03:46.976
And then we have independent confirmation from three countries actually, when they talk about the deep margin elevation 2012, Pascal Magne and Roberto Spreafico specifically published that article.
00:03:47.076 --> 00:03:57.420
And then in 2014, a German group did the same long term in vivo study in vitro and in vivo studies compared.
00:03:57.521 --> 00:04:13.903
And then in 2019 we had a long term 12 year study from David Gerdole and his associates in France and in Holland, particularly Marco Gresnigt in following these deep margin elevations.
00:04:13.970 --> 00:04:15.338
Long term.
00:04:15.338 --> 00:04:19.375
So let's talk about how did I first do my first deep margin elevation?
00:04:19.475 --> 00:04:25.882
Well, it has the history in that with traditional dentistry, I was doing a lot of root canals.
00:04:25.882 --> 00:04:49.406
And so with root canals that had been caused from leakage and decay around deep class two restorations, I had the opportunity to learn how to be a better and at honest, and I took advantage of that and that was from courses given by my class valedictorian at University Pacific, Steve Buchanan.
00:04:49.506 --> 00:05:00.850
Steve Buchanan had revolutionized the anatomic world when he started to embrace mechanical rotary instruments, nickel titanium files, and he became very popular speaker.
00:05:00.850 --> 00:05:10.927
And I went to many of his lectures at ADA convention, and then I did a hands on course with him and that hands on courses in 1999.
00:05:10.994 --> 00:05:13.997
And that was the first time I was introduced to a microscope.
00:05:14.197 --> 00:05:17.600
And then I bought my microscope at the end of that year.
00:05:17.701 --> 00:05:24.341
But then in these times when I was becoming a very proficient endodontist, I would do my own endo.
00:05:24.341 --> 00:05:28.110
And then after I had done that, then I would restore the tooth.
00:05:28.211 --> 00:05:49.432
But the situation in endodontics is that you must isolate the tooth to prevent bleach, which is the irrigating solution from going into the patient's mouth, which is never a good if the patient is having the bleach put into there into their oral cavity.
00:05:49.533 --> 00:05:58.141
So what I'm doing my endo, if I have a deep sub marginal defect that I'm trying to isolate, that's a problem.
00:05:58.307 --> 00:06:04.281
Traditional techniques would say, well, you could go and do a crown lengthening surgery.
00:06:04.281 --> 00:06:05.915
I knew how to do that and I could do that.
00:06:05.915 --> 00:06:07.951
But then there's a healing time.
00:06:07.951 --> 00:06:24.968
But the idea came to me when I was getting ready to do a molar and at our treatment that if I built up the deep sub gingival wall with composite, which had been, you know, started training two years before with Ray Bertolotti.
00:06:25.035 --> 00:06:32.943
then I could isolate the tooth with the rubber dam easily and there would not be a problem with bleach contamination.
00:06:33.009 --> 00:06:54.931
So I did my first deep margin elevation, 1998, early 1998, and I did it with the chemical cure materials that I had chemical your bonding system, photo bond and the dual cure material that it was called the best field to be made by Ray Bertolotti from Biscoe.
00:06:54.931 --> 00:07:09.346
And this technique that I use to elevate this margin once it was bonded, allowed me to isolate and do my ended on a treatment, but then my ended on a treatment was done.
00:07:09.412 --> 00:07:26.963
And I'm looking at this bonded box that I had full confidence in, even though in 1998 I didn't have all the details of hierarchy of Bondability and dental flow with chemical cure composites that we talked about last episode.
00:07:27.129 --> 00:07:31.634
But I did know that the C factor was very low why?
00:07:31.701 --> 00:07:43.280
because I actually could see the bonded surface is just the shell of the box bonded on two thin sides of the mesial and buccal and one box depth.
00:07:43.346 --> 00:07:54.357
But then the on bonded surface of that wall that was being built to isolate tooth that had a huge unbonded ratio.
00:07:54.456 --> 00:07:56.092
It was very, very low.
00:07:56.092 --> 00:08:01.631
Therefore the shrinkage of the composite would not stress the bond very much.
00:08:01.698 --> 00:08:06.468
It would shrink not away from a wall, but towards the center of mass.
00:08:06.603 --> 00:08:09.105
You know, the I could make an illustration of that.
00:08:09.105 --> 00:08:13.410
It's a little bit complicated if you haven't been trained in the six lessons.
00:08:13.410 --> 00:08:23.485
But still, the idea is that I elevated a deep margin 3 to 4 millimeters with chemical pure composite.
00:08:23.485 --> 00:08:30.994
I used a dual cure bonding system photo bond, and then once I had that done, allowed me to do the handle.
00:08:30.994 --> 00:08:34.463
And then the question was traditional techniques.
00:08:34.463 --> 00:08:37.933
In 1998, I'm still going between crowns.
00:08:37.933 --> 00:08:39.936
No crowns, crowns, no crowns.
00:08:39.936 --> 00:08:43.173
So I felt comfortable in large composite.
00:08:43.273 --> 00:09:13.669
Obviously I've been doing crowns successfully for 18 years, but I looked at their restoration and I'm saying I'm not going to take that off so that I can create a perfect ferrule A ferrule by definition is two millimeters of sound to structure that is going to give the firm foundation that the Crown is going to attach to, but that ferrule was going to be two millimeters sub gingival.
00:09:13.769 --> 00:09:39.062
And so I had to deal with the gingiva, which would be a surgical procedure or if I have the bonded deep margin and it sealed and I'm not relying on mechanical retention which a Farrell is part of in a Crown retention, but I'm just going to be relying on adhesive compliant planning in this situation to do a large inlay actually.
00:09:39.162 --> 00:09:50.774
And so at that point I said, look, the rest of my tooth, the bond to dentin has been established was actually established 24 hours ago.
00:09:50.774 --> 00:10:01.051
I had finished the Endo patient came back actually the next day and I had this bonded surface and I said, I'm just going to add to that surface.
00:10:01.051 --> 00:10:04.320
So the immediate dentin sealing is in place.
00:10:04.421 --> 00:10:12.995
There's been no stress on the dentin bond of all of the dental surface around the root canal, access to the pulp chamber.
00:10:13.196 --> 00:10:19.068
I didn't edge, but I knew that the composite, the immediate end ceiling should be cleaned a little bit.
00:10:19.134 --> 00:10:23.940
And so that surface was rinse dried that point.
00:10:23.940 --> 00:10:32.481
I'm not sure if I had air abrasion, but I added another layer of adhesive on to my immediate and ceiling.
00:10:32.481 --> 00:10:40.389
And then I looked at my preparation that was immediate and sealed and then the deep margin was elevated in the back.
00:10:40.456 --> 00:10:43.058
And then I said, Well, there's some undercuts here.
00:10:43.058 --> 00:10:49.666
I can change the geometry by taking out those undercuts by adding composite bonded composite.
00:10:49.733 --> 00:11:02.979
So I changed the geometry of the large inlay shape preparation by one doing the deep margin elevation separately and then removing any undercuts by an additive technique.
00:11:03.046 --> 00:11:18.260
And all of a sudden I had a nice, smooth and flat on the bottom and smooth on the side inlay preparation that had composite on the gingival floor that it had been elevated and then composite on the buckle and lingual walls.
00:11:18.360 --> 00:11:26.603
And I had now a nice inlay preparation that had draw and I took that impression and made my inlay my large inlay.
00:11:26.603 --> 00:11:31.774
And then cemented it with protocols of a resin cement.
00:11:32.008 --> 00:11:42.918
And after that was done in 1998, I looked at it and I said, Well, I wonder if anybody else in the world is doing this.
00:11:42.985 --> 00:11:46.322
And, you know, I was determined to find out.
00:11:46.322 --> 00:11:58.935
So 1998, I went to the ADA convention and May, had lunch with Bortolotti and met Gary Unterbrink for the first time and heard John Cank and Charlie Cox heard the name John Kois.
00:11:58.935 --> 00:12:01.937
I mean, 1998 was that year for me.
00:12:01.937 --> 00:12:08.610
That really got me into a commitment of learning as much as I can about adhesive dentistry.
00:12:08.812 --> 00:12:19.221
But in 1998, the published book from Dietschi was this book, and I purchased that at the convention 1998.
00:12:19.288 --> 00:12:29.465
It did not have deep margin elevation in that book, but I had the opportunity to talk with Gary Unterbrink, talk with Ray Bertolotti.
00:12:29.532 --> 00:12:38.173
They didn't see any any problem with having a resin base underneath the composite restorations, just making it larger.
00:12:38.240 --> 00:12:57.192
But the separation of these two masses of composite the inlay and the resonance base to me was now becoming clear that the key factor determined portion of my deep marginal elevation that I had made was the correct one.
00:12:57.259 --> 00:13:03.233
Again, I didn't have decoupling with time and hierarchy bondability in 1998 fully in my mind.
00:13:03.332 --> 00:13:16.312
But as I saw this restoration go on for the next few years, I visited Didier Dietschi as I took a course two day course at UCLA in the year 2000.
00:13:16.379 --> 00:13:27.456
I wanted to see if he had figured out this deep margin situation he had, but he had not figured out the hierarchy of bond ability and the decoupling with time.
00:13:27.456 --> 00:13:30.759
But still we talked about marginally elevated.
00:13:30.927 --> 00:13:42.138
Yeah, I just published a paper coming out this year and that paper will show that for the first time and this is the paper and it's a paper that the title had nothing to do with.
00:13:42.138 --> 00:13:55.018
The marginalization says current clinical concepts for adhesive segmentation of tooth colored posterior restorations is the first time that heated composite is used to see these inlays launches.
00:13:55.118 --> 00:14:17.105
But in that article there was a very small illustration, and this small illustration had immediate debt and ceiling and a deep margin elevation, not a very deep one, but it was definitely a situation where the bio base is created first by a base that was wasn't named until 2003.
00:14:17.105 --> 00:14:26.349
It's now in Magne Belser’s book, but Wendell Robertson came up with the bio based term, I have popularized it.
00:14:26.416 --> 00:14:35.057
But that paper in 98 was part of Dietcshi’s investigation that he was carrying on, and eventually he got a Ph.D.
00:14:35.091 --> 00:14:56.512
dissertation, and that dissertation publication contained two articles that had been published in a kind of an obscure journal for Americans, European Journal of Oral Sciences, but that these two papers gave the information that the composite should be used for this deep margin elevation.
00:14:56.579 --> 00:15:04.419
Composite had characteristics that were more tooth like didn't use the term biometric, but that's what he meant.
00:15:04.653 --> 00:15:15.630
And then as the years went on, I came to in 2005 to visit Pascal Magne to see what he knew and see what he was doing and what his plans were.
00:15:15.731 --> 00:15:32.048
Because I've been teaching the six lessons for two years and the first case that I showed him was that the deep margin elevation that I did in 1998, so this is at USC in 2005, this restoration is now seven years old.
00:15:32.115 --> 00:15:37.052
And I showed it to Pascal and he said, Nobody's published that yet.
00:15:37.153 --> 00:15:38.187
And I said, I know.
00:15:38.187 --> 00:15:47.096
I've been looking at the literature and talk with Dietschi He hasn't published the case, but he had an illustration that he said was going to be in the new article.
00:15:47.096 --> 00:15:51.734
And at 2005 then I did have access to that article.
00:15:51.801 --> 00:15:56.239
But anyway, the idea was that in Geneva they were doing this.
00:15:56.239 --> 00:16:03.812
I had been doing this my office, 1998 was the year that we both figured this out independently.
00:16:03.913 --> 00:16:18.594
We fast forward as we keep practicing dentistry and doing dentistry, and I'm teaching dentistry now to dentists, practicing dentists in 2003 and the dissertation from Dietschi is published, I get a copy of it from Pascal.
00:16:18.693 --> 00:16:20.096
He had a copy in his office.
00:16:20.096 --> 00:16:26.635
I borrowed it and made a copy of actually made three copies, gave one to Simone Deliperi and that Ph.D.
00:16:26.668 --> 00:16:29.672
dissertation is an outstanding piece of work.
00:16:29.806 --> 00:16:31.474
I thanked Dietschi for this.
00:16:31.474 --> 00:16:32.108
Last year.
00:16:32.108 --> 00:16:51.860
When I spoke with him, Davey and I were on the same stage, the same conference in Chile, but you know, working these concepts out until it becomes taught and then practiced and then monitored long term, that's a more difficult thing to do.
00:16:51.961 --> 00:17:01.370
The first paper published by Pascal Magne and Roberto Spreafico, he actually said that this deep margin elevation was a paradigm shift.
00:17:01.471 --> 00:17:16.551
Obviously, it's something that, you know, bonding or restoration to a composite base, people that don't know composite chemistry and don't know the the difficulties of it and are very afraid to do that.
00:17:16.652 --> 00:17:26.995
But to those of us who became masses of adhesive dentistry early on, we understood that this had the ability to connect with the two side to side front.
00:17:26.995 --> 00:17:31.500
The back and top the bottom in that 30 plus megapascal range.
00:17:31.733 --> 00:17:35.637
And this has been proven that's science.
00:17:35.737 --> 00:18:00.028
But then to get enough people to do it and follow it, there's two important papers that were published, the one out of Germany and the title was Proximal Black Box Elevation with resin Composite and the dogma of biologic width clinical are two technique and critical review.
00:18:00.028 --> 00:18:01.796
They called it the R two technique.
00:18:01.796 --> 00:18:11.406
They should have called it the deep margin elevation two years before Magne Spreafico were the first ones to put that term in to publication.
00:18:11.473 --> 00:18:17.312
There had been a USC manual in 2006 that included that.
00:18:17.413 --> 00:18:19.648
But you know, that's kind of splitting hairs.
00:18:19.648 --> 00:18:53.181
But the Germans, what they wanted to investigate is why these sub gingival composites were not bleeding because the myth or the dogma of biologic with the violation that every periodontist and president is working in, in conjunction felt like it was a reaction of the tissue to the Crown material where in reality it was a reaction to the biofilm underneath the crowns that were not bonded and did not stop this gap formation underneath crowns and fillings.
00:18:53.281 --> 00:19:09.664
So inflammation of gingival of an amalgam or inflammation of gingival of a composite or inflammation of gingival of a crown is actually related not to the material but to the bacteria that are underneath the crown or the filling.
00:19:09.865 --> 00:19:12.667
And so that's what causes the inflammation.
00:19:12.667 --> 00:19:20.075
If you stay bonded in these deep margin elevations, then that inflammation goes away.
00:19:20.141 --> 00:19:36.758
This paper by Bresser and Gerdolle, Heijkant, Pouwel, Cune and Marco Gresnigt my good friend at Groingen University in Holland, their papers showed 95% no inflammation on any of these deep marginal nations.
00:19:36.758 --> 00:19:42.130
Some of these been followed 12 years published in 2019.
00:19:42.330 --> 00:19:48.303
And so my cases are more than 20 years old and the same situation is they stay bonded.
00:19:48.370 --> 00:19:54.342
There's no inflammation, there's no biofilm underneath the crown or the restoration.
00:19:54.409 --> 00:20:03.852
And so the biologic reaction, the inflammatory reaction of the gingiva to these bacteria is what's called what causes this inflammation.
00:20:03.852 --> 00:20:12.560
And often associated with bleeding, as the inflammation is into the connective tissue portion of the gingival attachment.
00:20:12.627 --> 00:20:17.966
Wow. So that's how deep marginalization has got going.
00:20:18.067 --> 00:20:21.803
And they're possible with composite.
00:20:21.903 --> 00:20:28.677
They're not possible long term with resin modify, glass, monomers and glass enemas.
00:20:28.777 --> 00:20:43.291
It's a little discouraging when I hear training that some of the top dental schools where they're actually still doing deep marginalization with glass eye armor, that's also called an open sandwich technique.
00:20:43.391 --> 00:20:58.139
That technique was thoroughly debunked in the late eighties because the glass monomers were brittle under functional stresses they would break down in the years 4 to 6, there are no 20 year deep margin elevations using glass.
00:20:58.139 --> 00:21:05.680
I honor the successful cases, but it's still being taught in the couple of dental schools around which it wasn't being taught it.
00:21:05.747 --> 00:21:15.256
It'll be good for four or five years, but then you have to redo it because it breaks down underneath your composite only in layer restoration.
00:21:15.256 --> 00:21:17.659
And that comes from solid science.
00:21:17.659 --> 00:21:20.462
The Ph.D. work of Dietschi.
00:21:20.462 --> 00:21:26.234
Consider him one of my early mentors, of course, Ray Bertolotti and Gray Unterbrink.
00:21:26.301 --> 00:21:34.576
Didier Dietschi I was very impressed with everything that he was doing as far as minimally invasive and adhesive dentistry.
00:21:34.576 --> 00:21:42.684
Of course, esthetically just totally beautiful, and after the course it was actually under the direction of Ed McLaren at UCLA.
00:21:42.684 --> 00:21:48.323
He was teaching a cosmetic dentistry master course at UCLA at that time.
00:21:48.323 --> 00:21:55.830
But the and Ed McLaren and I were talking, I said, I think you're the best dentist the world, but who do you think is the best dentist?
00:21:55.830 --> 00:22:02.737
And he without hardly even thinking, said Urs Belser, because I hadn't heard his name.
00:22:02.737 --> 00:22:04.939
I had read it, but not remembered it.
00:22:04.939 --> 00:22:14.149
You wrote part of the introduction to Dietschi’s Book, and Urs Belser was the mentor of Didier Dietschi and the mentor of Pascal Magne.
00:22:14.215 --> 00:22:31.199
And Belser was is a president who mastered all areas of prosthodontics and all areas of implant dentistry associated with prosthodontics and Belser’s a top researcher, teacher, the administrator, just a great human being from all reports.
00:22:31.199 --> 00:22:41.075
I haven't met him personally, but Belser basically told Dietschi if adhesive dentistry lives up to his potential, it will eliminate most of the endo.
00:22:41.142 --> 00:22:48.950
It will eliminate most of the perio, it will eliminate prosthodontic destruction of tooth structure.
00:22:49.017 --> 00:22:58.693
And so all of the specialty disciplines, including implants, will be majorly impacted by implementing adhesive dentistry.
00:22:58.860 --> 00:23:03.665
Now, if you're a specialist, you might not like to hear that message.
00:23:03.731 --> 00:23:09.671
I know when I told Steve Buchanan about the six lessons 21 years ago, he had lunch.
00:23:09.671 --> 00:23:13.508
I said, Steve, this is going to prevent a lot of endo.
00:23:13.508 --> 00:23:17.879
And he looked at his says, Great, He's very busy in Santa Barbara.
00:23:17.879 --> 00:23:18.880
Still is.
00:23:18.880 --> 00:23:27.021
He's still teaching and practicing, I believe in Santa Barbara, but he changed the world of endodontics The world paradigm has changed.
00:23:27.021 --> 00:23:38.433
Unfortunately, it's mostly based on extracting teeth that could be saved with the periodontal treatments and good restorative treatments like biomimetic dentistry.
00:23:38.500 --> 00:23:43.371
But these evolutions Belser was for he felt like it was progress.
00:23:43.371 --> 00:24:04.959
As long as we're conserving to structure and conserving pulp tissue, Belser understood the difference between a vital and a non vital tooth and all of the investigations since the early 2000s of reinforce the idea that a brittleness comes from antibiotic treatment that cannot be remedied.
00:24:05.026 --> 00:24:17.505
A tooth that has entered our treatment has three times the potential to fracture because it's three times as brittle and it's only a third of the engineering term as toughness.
00:24:17.572 --> 00:24:22.211
So a tough tooth, tough material flexes a brittle tooth.
00:24:22.211 --> 00:24:32.620
Their brittle material begins to fracture through crack initiation, crack propagation, and finally catastrophic failure.
00:24:32.687 --> 00:24:35.123
Anyway, the lot to think about.
00:24:35.123 --> 00:24:38.493
But here we are change the world.
00:24:38.560 --> 00:24:41.863
They'll next time get bonded. They bonded.
