Very Clinical: Dr. Nate Lawson is a Fan of Onlays (and Partial Coverage)

[00:00:00] This is a production of the Very Dental Podcast Network.

[00:00:16] Welcome to the Very Clinical Podcast. In about the time it takes to do an MO on three, we will entertain and amaze you with tips and tricks on regular daily dentistry. Here's Kevin and Zach.

[00:00:28] What is up, Very Clinical listeners, and welcome to our first episode of 2023.

[00:00:34] This is Zach Miners coming from Kansas City Mo and with me as always, Dr. Kevin Harefriar. Kevin, what's going on, my man?

[00:00:40] Hey, Happy New Year, man.

[00:00:43] To you, the same.

[00:00:44] New Year, new you.

[00:00:46] That's what I always say. That's what I start my day with on the first for sure.

[00:00:51] Are you different today than you were on New Year's Eve?

[00:00:55] Oh, you know me.

[00:00:55] Absolutely. Absolutely, completely different.

[00:00:57] What is the cutoff for when you can tell people Happy New Year? What's the day?

[00:01:02] See, this is a weird thing because I have a lot of patients that all through January will say Happy New Year to me.

[00:01:08] Yeah, I hate that.

[00:01:09] It happened a month ago.

[00:01:11] Right.

[00:01:12] I don't understand that at all. It's not the same to me as other holidays.

[00:01:17] No.

[00:01:18] Like right now you can be like, hey, have a happy holiday.

[00:01:20] Merry Christmas or whatever. Happy holidays.

[00:01:23] But like once it's over, it's done to me.

[00:01:26] So New Year, what's the cutoff? What do you think? Fifth? Third? Is it already now?

[00:01:31] Um, 12.01.

[00:01:34] Oh, well, we already blew it then. Jeez. Okay.

[00:01:38] All right. Hey, Kevin, we're starting off our year with a bang.

[00:01:41] We've got Dr. Nate Lawson returning guest.

[00:01:44] I think you're officially like in the like five or six timers club now, Nate.

[00:01:48] What's up, my man?

[00:01:50] Not too much.

[00:01:51] Yeah, it's like SNL where you get like a jacket after.

[00:01:54] Jackets in the mail.

[00:01:55] Oh, okay. Good.

[00:01:57] No, you're on the yearly rotation almost like, uh, you know, John Goodman in the eighties or Justin Timberlake in the 00s.

[00:02:04] Something like that. I like it.

[00:02:06] Or Steve Martin throughout the whole, all the decades.

[00:02:08] Yeah.

[00:02:09] He's the one I, he's the one I always think of is the multiple host guys.

[00:02:14] I, he's actually, he just hosted a couple, couple weeks ago.

[00:02:17] So yeah.

[00:02:18] Yeah.

[00:02:18] And, uh, him and Martin short together.

[00:02:21] So yeah.

[00:02:23] Very cool.

[00:02:25] Uh, Kevin, what do we, what do we got here this evening?

[00:02:28] Well, um, you know, I always, uh, on my Facebook page around the end of the year, do a Kevin's top

[00:02:34] seven of, um, top TV shows or movies.

[00:02:38] And they're tended more towards TV shows, uh, since the old pandemic hit us.

[00:02:44] Don't go to the movie theater as much.

[00:02:45] So, um, I thought we would discuss our top TV shows or series or documentaries or streaming, whatever that we watched in 2022.

[00:02:59] Now that it's 2023.

[00:03:02] So I'm going to go last.

[00:03:03] So Zach, are you just going to run the horn on my screen here?

[00:03:07] I'll defer to our guest.

[00:03:08] Oh, that was brutal.

[00:03:10] Okay.

[00:03:10] I can do it.

[00:03:12] I, I, I, I've been thinking about this.

[00:03:14] Yeah.

[00:03:14] So, I mean, for me, an obvious one would be half of dragons because I've, I, uh, I didn't

[00:03:21] think I was going to watch it because I was so disappointed by the end of the game of Thrones.

[00:03:24] I was, I was going to like never watch any of those series again.

[00:03:27] And then it started and I was like, this is actually pretty good, but I'm going to go with something different.

[00:03:31] I'm going to go with, um, white Lotus season two.

[00:03:34] Uh, I really, I really loved white Lotus season one.

[00:03:38] Um, and when the first episode of the second season came out, I thought it was, first of all,

[00:03:44] it was kind of tacky and I didn't think I was going to like it, but I, I really enjoyed that, uh, that season.

[00:03:50] I think the thing I like about it is it's like, you feel like you're going on vacation with these, these people in these beautiful settings.

[00:03:57] And they do, you know, in between scenes where they've got action going on, they'll show these like shots of the scenery.

[00:04:06] And this, this season it was in somewhere in Italy and it was just beautiful.

[00:04:10] Yeah.

[00:04:11] I actually looked up that hotel, uh, to see if it was real.

[00:04:14] I mean, obviously it has to be real, but, um, a huge white Lotus fan white Lotus season one was awesome.

[00:04:22] Season two.

[00:04:23] Um, I guess by the time this podcast fine comes out, we'll know what happens, but, um, did you watch?

[00:04:30] I'm still waiting for, uh, there's so many things that could possibly, um, be the result.

[00:04:37] Um, it's, it's, it's really a great season.

[00:04:40] I, I too thought this was going to be like a downer, but I'm really into it.

[00:04:45] Okay. Good.

[00:04:46] I'm glad, glad a critic like you, Kevin can also, uh, give a thumbs up to it.

[00:04:53] Yeah. Love it.

[00:04:55] Okay. Uh, yeah.

[00:04:57] All right. Kevin, you, you know, uh, from talking to me over the years that I'm, I tend towards the, the nerdy sci-fi, uh, Taco Bell content, as you like to call it.

[00:05:07] Yes. And, um, uh, this year I really enjoyed, uh, Neil Gaiman's, the Sandman on Netflix.

[00:05:14] I don't know if you were familiar with the, the Sandman. It's a story of the, the God of dreams descending into hell and all this stuff.

[00:05:22] It's, it was a cool story. It's been a iconic story since the, uh, it came out in the nineties and, uh, Netflix did a pretty good job, uh, bringing it to life.

[00:05:31] And, uh, they got, got green lit for additional seasons. So it was a, I, like I said, I, I've enjoyed that comic since I was a kid and they did a nice job of, uh, translating it.

[00:05:41] So the Sandman on Netflix, good stuff.

[00:05:44] All right. So I'm going to go with a non Taco Bell item.

[00:05:49] Of course you are.

[00:05:50] That I've been obsessed with for the whole summer and, um, up until, um, every day, I cannot stop thinking about this. So are you guys familiar with the comedy central show from the around 2016 ish of, uh, Nathan for you.

[00:06:08] Oh, yes. Yeah. So Nathan Fielder. Yes. I'm familiar with that. He had an HBO show called the rehearsal, which I am obsessed with. And unfortunately there's no way I can describe what this show is about because it's just too hard to describe.

[00:06:29] Um, and, um, because I am prone to overanalyzing things and I have a nephew and a wife that are also good at overanalyzing things. We have digested this inside and out. And we've come to the conclusion that this is really not a TV show.

[00:06:43] It's an art piece that is sort of poking fun at television in general and, um, setting up your expectations of things. Uh, it's, it purports to be a reality show, but it's very difficult to see where the reality is. And the scripted part is, it's just a brilliant, um, five or six episodes.

[00:07:13] Uh, of wondering what the heck is going on and how this is all going to end. And, um, like I said, I'm obsessed by it. So, you know, I don't think it's for everyone, but if you want to have your mind blown in multiple ways and have your jaw dropped to the floor a couple of times, uh, check out the rehearsal on HBO.

[00:07:36] Would you define it as more comedy than suspense or drama?

[00:07:43] It's definitely cringe comedy.

[00:07:46] Cringe comedy. Okay. All right.

[00:07:47] And, uh,

[00:07:48] I don't think it likes that genre because he's a curb guy because we've had that discussion enough times.

[00:07:52] It's cringe comedy and also just playing with the form of television.

[00:07:59] Um,

[00:07:59] Um, okay.

[00:08:00] And so you have certain expectations of things and those aren't going to happen or you'll have the curtain pulled back on you and, um, see what's going on behind the scenes.

[00:08:11] Or is it?

[00:08:15] Oh man.

[00:08:16] I still haven't finished it.

[00:08:18] Um, but I, the funny thing is I watched the first episode and the first episodes, you know, he doesn't get into kind of the meat of the show, I think until the second episode.

[00:08:26] And so I didn't watch the second episode for a long time until someone said, no, you got to go with the second episode and just kind of see where this, where this goes.

[00:08:35] There's a clue in the first episode in the credits.

[00:08:38] It plays that the Willy Wonka, um, pure imagination theme song.

[00:08:45] Okay.

[00:08:46] And the, the portion of the lyrics that they, they chose to put over the credits really explain what's going to happen next.

[00:08:55] Okay.

[00:08:56] And my premise is that I have two premises, either it started off as one show and COVID made it into something else because being isolated in Oregon or whatever they were later on, um, makes sense in that context.

[00:09:11] Or that that episode was shot last and they sort of filled in the blanks.

[00:09:18] But if you're listening to this and you're familiar with, uh, Willy Wonka and the Chocolate Factory, the original one, uh, just keep that in your head the whole time.

[00:09:28] Because, uh, there is a scene.

[00:09:31] I'm not spoiling anything in which, uh, in the first episode between Nathan and core.

[00:09:36] And, uh, core says, you're like Willy Wonka to Nathan.

[00:09:41] And Nathan says, huh, isn't he the bad guy?

[00:09:44] And core kind of responds last.

[00:09:47] And, and Nathan says, I'll have to read that book again or watch that movie again, which is totally a setup because, uh, there's a surprise at the end.

[00:09:58] And I will show you guys when this is done, um, what the surprise is.

[00:10:04] So if you keep Willy Wonka in mind and how Willy Wonka is kind of just in, in Willy Wonka is sort of an unreliable character, but is sort of manipulating everything in the background.

[00:10:18] That's what you need to keep in mind throughout the whole thing.

[00:10:21] Cool.

[00:10:22] All right.

[00:10:23] Enough.

[00:10:24] Mind blown.

[00:10:25] Yeah.

[00:10:25] I mean, I think about it every day.

[00:10:28] I need to finish the show now.

[00:10:30] Yeah.

[00:10:31] Uh, Nate, give our, uh, guests that might have missed your previous episodes.

[00:10:34] Give us a quick, quick overview of your, your bio and what you, what you do real quick.

[00:10:40] Yeah.

[00:10:41] So I'm a general dentist.

[00:10:43] I went to the university of Alabama at Birmingham and I did a combined DMD and PhD.

[00:10:49] And then I graduated practice for a couple of years in Chicago where I'm from and then came back to the school to start teaching.

[00:10:57] Teaching, teaching is kind of like, uh, one way to describe what I do.

[00:11:01] So I teach dental students.

[00:11:03] Um, but my kind of main thing is I am the director of our materials department at the school.

[00:11:10] So I've got a two year master's program with six residents and we do testing on different types of dental materials.

[00:11:17] So ceramics, adhesive composites, um, all those types of materials.

[00:11:21] Uh, and so we work with companies as they come out with new materials and we kind of evaluate them.

[00:11:27] And then I, uh, one of my other big passions is, um, spreading that information through social media or through doing external, uh, flat sharing.

[00:11:36] So that's kind of me in a nutshell.

[00:11:39] And you can find, uh, you know, Nate's stuff at, at, at dentinal tube.

[00:11:45] And let's see how many followers are you up to now?

[00:11:47] Holy smoke.

[00:11:49] 93,000.

[00:11:50] Goodness, Nate.

[00:11:51] That's, that is, that's incredible.

[00:11:54] That is incredible.

[00:11:55] Exactly.

[00:11:56] Yeah.

[00:11:56] That's, um, I think we had an episode on, on, on social media, the good and the bad.

[00:12:02] Oh yeah.

[00:12:03] Or at least had a conversation on previous episodes, but yeah, it's been, um, it's been cool.

[00:12:08] One of my favorite new accounts to follow.

[00:12:10] I don't know if you guys already follow him is, I mean, it's not new account, but he's just been killing it recently.

[00:12:14] It's Marcus Blatt's.

[00:12:15] I was just, um, I have to do a Maryland bridge, uh, in like, I think in two weeks and I went on his page and, you know, he's got all the prep designs for doing Maryland bridge.

[00:12:27] And he's just got a lot of great content on adhesive dentistry.

[00:12:31] It's Marcus.

[00:12:32] Marcus, I think that the account is just, uh, B L A T Z.

[00:12:38] Okay.

[00:12:39] All right.

[00:12:40] We'll put that in the, we'll put that in the show notes, but, um, yeah.

[00:12:43] Yeah.

[00:12:44] I love how comprehensive Nate's, um, Instagram stuff is.

[00:12:49] I really appreciate it.

[00:12:51] He's, he's definitely.

[00:12:52] And he has more followers than REO Speedwagon.

[00:12:55] So, you know, that's, that's notable.

[00:12:57] It's notable.

[00:12:58] They have a lot of number one hits, you know, that's a big deal, Kevin.

[00:13:00] It's a big deal.

[00:13:02] Uh, okay, Nate, what's the, uh, what's the hot topic tonight?

[00:13:06] We have, we have a couple of things to, to hit and what's, what's something you've been posting about lately or thinking about or doing lately?

[00:13:13] Yeah.

[00:13:14] I mean, so the topic that I was thinking with Casano talking about was, um, partial coverage restorations.

[00:13:22] And as we kind of chatted in the pre-show minutes, uh, Kevin.

[00:13:27] In the green room.

[00:13:28] In the green room.

[00:13:29] Green room.

[00:13:30] Yes.

[00:13:30] Where you guys gave me the, the caviar that you mailed to me.

[00:13:34] That's right.

[00:13:37] In the campaign.

[00:13:49] Yeah.

[00:13:49] It's probably a good place to start as we talk about partial coverage or onlays or crownlays or whatever you mean.

[00:13:57] Maybe I'll, I don't mind starting off.

[00:13:59] Like kind of what I, how I, what I think of or what I do is I don't do inlays.

[00:14:04] I think onlays are kind of silly.

[00:14:06] Like if I'm going to be doing something that's that small, I'll just do a direct composite.

[00:14:11] Um, most of the onlays that I'm doing, honestly, at this point, I very rarely preserve a cusp.

[00:14:17] I mean, there are basically these crownlays where I'm taking off the complete occlusal surface.

[00:14:25] And, um, most of the times they're large MOD amalgams.

[00:14:29] I mean, there's like half the time MOD amalgams.

[00:14:30] I'm going to, I'm going to take out the mesial and distal, uh, boxes and I'm going to take out the complete occlusal surface.

[00:14:38] And the only difference on, I mean, kind of between that and a crown prep is the buccal and lingual walls instead of kind of mowing them down and keeping them all super G and preserving that, that tooth structure.

[00:14:50] So, you know, is it a, is that an onlay or a crown lay or what do you, you know, what, what do I call it?

[00:14:56] I, I, I call it a, I call it to my patients an onlay.

[00:14:59] I, when I write in my notes, I call it a crown lay because a lot of times I'm kind of billing it out to insurance is a, is a crown.

[00:15:06] So to keep my notes consistent with my story, I kind of call it a crown lay.

[00:15:10] So it just has crown with, you know, my buccal and lingual margins are just kind of elevated.

[00:15:16] And, um, and yeah, so that's kind of my, uh, what my go-to for partial coverage.

[00:15:22] Um, so, you know, basically minimum of like, you know, a minimum of a cusp of coverage and more, most likely three or four cusps of, of coverage on, on that.

[00:15:35] And so before we get in much further with that, Kevin is, is an onlay on the table at your office or is it not really, um, something you're going to consider most of the time?

[00:15:47] Uh, not anymore.

[00:15:49] Okay.

[00:15:50] So that, that's my.

[00:15:51] Which is odd as a, as a Sarek guy.

[00:15:52] Yes.

[00:15:52] Because isn't that kind of what, uh.

[00:15:54] That's the Sarek game.

[00:15:55] What it was sold as?

[00:15:56] Yeah.

[00:15:57] So, uh, I'm going to, I'm going to let Nate extol all the virtues and then I will speak from my, being the oldest person in the room.

[00:16:08] I will speak from experience.

[00:16:10] But I'm not totally, I'm not totally against it.

[00:16:13] It's just, it's one of those, um, in my hands.

[00:16:17] How about that?

[00:16:18] Yeah.

[00:16:18] One of those in my hands.

[00:16:19] I love a good in my hand story.

[00:16:21] Yeah.

[00:16:21] I, I have, uh, not done an onlay in some time and I have the, the most, the majority of the ones that I do have that I see on recall, I did years ago with gold.

[00:16:35] You know, so I haven't done any of the Emax onlays or crown lays that the, uh, you know, uh, biomimetics guys show under, you know, rubber dam isolation and, um, all that kind of stuff.

[00:16:50] So that's, that's my story on onlays.

[00:16:53] And it's funny that you say that too, because I, sometimes I think about that in the, in like kind of where sometimes I feel like I live in dentistry is that I like a lot of the biomimetic stuff, like some of those concepts.

[00:17:05] But at the same time, I don't, I, um, practice somewhere in between biomimetics and like everyday dentistry.

[00:17:12] So it's like, I don't, don't take it.

[00:17:14] I can't, I can't manage to do it all, uh, all of the things that are done in, in biomimetics.

[00:17:20] But like, I take some of those concepts, like I think partial coverage is something that kind of falls within the realm, but like, yeah, I'm not, I'm definitely not like scanning with the rubber dam on.

[00:17:30] Like that's, um, sure.

[00:17:33] That's what about things like, um, IDS and that sort of thing?

[00:17:37] So, yeah, so the, um, immediate dentinal seal, uh, it, so, I mean, I know that maybe people listening and not be familiar with this technique, but it's, it really seems like it would be good for partial coverage because the ideal is you prep the tooth.

[00:17:54] And while the dentinal tubules are still clean, you put a layer bonding agent on there and you leave it on there while the patient's in provisionalization.

[00:18:03] And then when the patient comes back in, you just take off the temporary and you've got this layer of bonding agent that's on there that was applied when the, uh, well, the dental tubules were still fresh.

[00:18:15] And to me, my biggest, um, issue, I guess with IDS is that, uh, there was a paper that was put out by Pascal Mignay and he was one of the people on this and he's a big proponent of IDS that showed that unless you use a super thick bonding agent, you have to put a layer of flowable on top of the dentin.

[00:18:33] Because if you don't use like the Optibond FL like he does, which is super thick that when you put, when you have your temporary on there and you want to clean up your temporary, they recommend sandblasting it.

[00:18:44] Sandblasting will take off any thin bonding agent.

[00:18:47] Oh, the layer.

[00:18:47] Oh, sure.

[00:18:48] So that layer of IDS.

[00:18:49] So, um, we don't use Optibond FL in the dental school.

[00:18:52] So we'd have to, I'd have to do IDS and then a layer of flowable and then temporize and then come back later.

[00:18:59] So I just hadn't, haven't completely gotten into it.

[00:19:02] I'm not opposed to the idea of putting a layer of bonding agent over my prep and curing it right before I, I'm scanning, but not milling in office.

[00:19:11] I'm scanning, but then temporizing.

[00:19:14] So I'll put a layer, I mean, I don't always do it, but I'll put a layer of bonding agent, cure it and then scan.

[00:19:19] But then when I come back later, I'm going to be putting, I'm going to kind of pretend like that layer is not even there.

[00:19:25] Like my, that bonding, like, uh, I'm going to reapply bonding agent.

[00:19:30] Gotcha.

[00:19:31] So I'm, yeah, I don't know if you have other opinions on IDS.

[00:19:35] So we sort of skipped ahead though.

[00:19:38] Yeah.

[00:19:39] What is your, um, what is your pro, your, your favorability for an onlay versus a crown?

[00:19:46] Yeah.

[00:19:47] Sell Kevin and I on the idea of it since we're, or anyone that's not really doing them maybe because they don't know how, or maybe because they don't know when.

[00:19:55] So let's, let's talk about the idea of it.

[00:19:58] Yeah.

[00:19:59] So, I mean, honestly, there's a couple of things I think about onlay.

[00:20:01] So first of all, uh, I mean, when I first started doing it, I had no idea what the hell I was doing because I wasn't taught to these in dental school.

[00:20:08] And I did these goofy prep designs where I'd leave like one single cuss sticking six millimeters up in the air.

[00:20:14] And I was like, I was going to deliver it and they wouldn't see it.

[00:20:18] And I just had no clue what I was doing.

[00:20:20] And, um, then I just started, I was actually somehow watching some of the CERC people and how they did these super smooth preparations.

[00:20:27] And there's a guy named, uh, I don't know if you guys have ever had Steve Schiffenhouse on the show, but he's, um, we haven't had him on, but we know who he is.

[00:20:34] I know who he is.

[00:20:35] Okay.

[00:20:35] Yeah.

[00:20:36] Yep.

[00:20:36] Um, so he, I'm smooth in house cause his preps are so smooth.

[00:20:40] And so, um, I like, uh, you know, the, the preps that he was doing.

[00:20:44] I think he might've, um, yeah, he, uh, so there were these just very smooth preps.

[00:20:50] And once I kind of got this prep form in mind, I find it was in some ways easier to do that tabletop prep than it was even to like start placing, you know,

[00:21:02] subgingival margins, uh, you know, for a full coverage crown.

[00:21:06] It's like, I mean, my crown preps, like some of my people I work with, their crown preps and I'll see their impressions or scans or whatever.

[00:21:13] And I was like, they have, they've, they've really got that down and they got these beautiful crisp, uh, margins.

[00:21:17] I'm sure you guys both have beautiful margins on your crown preps.

[00:21:20] Like my crown preps are never that beautiful.

[00:21:22] My on my own.

[00:21:22] When you scan them and see them blown up a hundred million times.

[00:21:24] I know.

[00:21:25] Yeah.

[00:21:26] It's true.

[00:21:26] That's depressing.

[00:21:27] It's going to change.

[00:21:28] Yeah.

[00:21:29] Yeah.

[00:21:29] But, uh, but yeah, I know my only,

[00:21:30] it's just a lot easier to do that.

[00:21:33] I mean, honestly, my preps just look nicer because it's easier prep to do in some ways.

[00:21:37] And then if I can keep my, my buccal lingual margins, super gingival, it's easier to scan those.

[00:21:43] It's still hard to scan the interproximal areas.

[00:21:46] And that's where I've kind of gotten into this margin elevation, uh, where I'll place matrix band and place some composite down in the mesial distal area.

[00:21:58] If my margins are subgingival.

[00:21:59] So then, I mean, now I can scan without packing any cords.

[00:22:04] So it was like, I mean, honestly, you know, I could sell it to you from the standpoint of like, oh, it's better for the patient because you're preserving tooth structure.

[00:22:11] So you're not compromising integrity of the tooth and all that these margins that are super gingival.

[00:22:16] So you can watch them.

[00:22:18] The patient can clean them easier.

[00:22:19] You could repair them easier.

[00:22:20] But honestly, some of it is just like, in some ways it does make it a little bit easier for me because my crown preps weren't ever that great.

[00:22:26] So now, this on-life prep, once you learn how to do it, it's really easier for me to prep and it's easier for me to scan.

[00:22:37] Okay.

[00:22:37] So, um, so that's kind of how I, I like.

[00:22:41] The knock's always been temporization.

[00:22:43] We touched upon that on the show.

[00:22:45] So like, you know, you've got this like smooth, you gotta get something to stick for, you know, the couple of weeks or whatever.

[00:22:53] Yeah.

[00:22:53] If you're not doing the same day, what are you doing?

[00:22:55] How does it work?

[00:22:57] Yeah.

[00:22:57] So when I first started doing it, I was temporizing with bisacryl, just like, you know, normal temps.

[00:23:02] And then, so I was trying to look for like stronger temporary cement.

[00:23:05] So we've tested temporary cements in our lab.

[00:23:09] And, um, like there's a material that's called TemposMID from DMG.

[00:23:13] It's like a resin-based temporary cement.

[00:23:16] And then there's this other company called Temrex TNE.

[00:23:19] I don't really know what else they make, but they make, I mean, I think the company's called Temrex and they make a temporary cement called Temrex TNE.

[00:23:24] Super strong resin-based temporary cement.

[00:23:27] And those two were really good.

[00:23:29] Uh, but then I found out about something even easier, which is, uh, using a material from Ivoclar called Telio Onlay.

[00:23:36] It's just like it, it kind of comes out like the consistency of a packable composite.

[00:23:42] You need to smush it on the tooth and have the patient bite together and then kind of smush it some more to adapt it.

[00:23:48] And light cure it.

[00:23:49] And then once you cure it, it's got like the stiffness of like a hardened gummy bear.

[00:23:54] Okay.

[00:23:54] And, um, and then, you know, I'm not going to say those never fall off, but they're super fast to do.

[00:24:01] And most of the time they stay on.

[00:24:02] I found the ones that fall off are the ones if it's the most distal tooth in the arch.

[00:24:09] Because, you know, you lock it in between the adjacent teeth.

[00:24:14] And so that's how it kind of stays in there.

[00:24:16] Um, and then there's like kind of advanced ways to try to do like spot bonding if you want to, you know, if it's the most distal tooth in the arch to get it to stay.

[00:24:24] But most of the time with the TLA, I'm just kind of smushing it in there and, um, and light carrying it.

[00:24:31] And honestly, again, it's an easier temp than a crown temp because I don't have to take a pre-op impression of the tooth.

[00:24:41] And I don't have to spend any time fiddling with waiting for my bisacryl to set.

[00:24:47] Um, so some of these things have, you know, they, again, they were tricky to figure out.

[00:24:53] But then after doing them, it's kind of like, you know, it's, it's, it's made it easier.

[00:24:59] So now it would be harder for me to do.

[00:25:01] I mean, I mean, I guess if this was a crown prep on like number, like a, like a first mandibular pre-molar, I mean, I guess those are pretty easy.

[00:25:11] But if I'm working on like tooth number 14, it's easier for me to do an on-lay than it is a crown-lay than it is for me to do a crown.

[00:25:21] Well, do you, do you have to anesthetize these when you go to, to bond them in then after you take the telio off?

[00:25:28] I would have.

[00:25:28] I do.

[00:25:29] Yeah.

[00:25:29] I would imagine you would.

[00:25:30] Yeah.

[00:25:31] Yeah.

[00:25:31] I don't, does everybody, does, is that not, even when I do crowns, I feel like.

[00:25:35] I always do.

[00:25:36] We've had this discussion.

[00:25:38] I don't want anyone to feel anything, even inadvertently, but.

[00:25:41] I don't know if the, I mean, if the, gosh, if the person's over 60, I can usually get away with taking the temp off.

[00:25:52] That's true.

[00:25:53] Sometimes.

[00:25:54] And cementing the crown on.

[00:25:55] Sure.

[00:25:55] If they're, if they're 30.

[00:25:57] Yeah.

[00:25:58] If it's a vital tooth, I always have to numb every single time.

[00:26:01] No, no matter what technique it means.

[00:26:04] But I could never get away with not numbing if I have to bond, you know.

[00:26:09] Oh yeah.

[00:26:10] And I mean, and of course, Kevin's not messing with this the majority of the time anyway.

[00:26:15] I don't always single and double preps because he's doing it the same day.

[00:26:17] So.

[00:26:19] I forgot.

[00:26:20] I didn't think about the fact.

[00:26:21] Cause yeah.

[00:26:22] Once you start.

[00:26:22] If you're bonding, you're going to etch the enamel and you got to rinse it off.

[00:26:25] And yeah.

[00:26:26] Yeah.

[00:26:26] It's going to be all my stuff.

[00:26:27] Yeah.

[00:26:28] Sure.

[00:26:28] That's the one that's, you never can.

[00:26:30] I guess the non vital tooth, you can probably get away with not having an estetite, but that's

[00:26:35] about it.

[00:26:36] That'd be the only, that'd be the only ones.

[00:26:38] Um, and so you're using Emacs on all of these.

[00:26:42] Is that correct?

[00:26:42] Cause that's your only, it's your bondable ceramic.

[00:26:45] Yeah.

[00:26:46] I mean, I've thought about this.

[00:26:47] You could, you could bond, uh, um, zirconia on life.

[00:26:52] You believe in zirconia bonding.

[00:26:55] And so I've played around with that.

[00:26:56] Zirconia bonding.

[00:26:57] I do.

[00:26:58] I think, I felt like we've had a podcast.

[00:27:02] We did.

[00:27:03] We did.

[00:27:03] I'll have to look through the archives.

[00:27:04] Yeah.

[00:27:05] Yeah.

[00:27:05] But yeah, I, I think you can.

[00:27:07] I mean, I'm not crazy.

[00:27:08] I'm not going to do it just for fun.

[00:27:10] I would only do that if, if I got something back from the lab and they said like, you've

[00:27:15] got 0.8 millimeters.

[00:27:16] Yeah.

[00:27:17] Reduction.

[00:27:17] And I'd be like, oh, maybe, maybe I want to do something stronger.

[00:27:20] So you're doing, the onlays that you're doing, you're doing them in Emacs or lithium, one

[00:27:24] of the lithium silicate products.

[00:27:27] What are you bonding these in with most of the time?

[00:27:29] Nate, I know there's a lot of good resin cements in the market, but what's your kind of your

[00:27:31] go-to right now?

[00:27:33] Um, so what we have at our school, I mean, what we've been, uh,

[00:27:37] we've had for the past three or four years has been, we use Scotch Bond for direct restorations.

[00:27:42] And so we've got the Reliax Ultimate, which is a cement that goes with it.

[00:27:46] So it's the green Reliax.

[00:27:48] Um, you know, they've got the newest version.

[00:27:50] 3M's got a new version of that cement, which is the orange one, which is Reliax Universal,

[00:27:56] uh, which I think that they might eventually try to phase out the Reliax Ultimate and just

[00:28:00] replace it with Reliax Universal.

[00:28:02] So the orange one, the advantage is you can use it with or without bonding agent.

[00:28:06] So it kind of like, it's like Reliax Unison and Reliax Ultimate in one.

[00:28:12] Um, and if the, the psychology, cause they realize how cheap we are as dentists and we

[00:28:17] get pissed off.

[00:28:18] Is it okay with this?

[00:28:19] Yeah.

[00:28:19] You can blame me.

[00:28:20] Um, that those tips, you know, that we waste material on those tips.

[00:28:25] Yeah.

[00:28:25] So they made the tips smaller.

[00:28:27] Um, so, uh, yeah, so that was kind of some of the, but the problem is that I'm at a dental

[00:28:33] school.

[00:28:34] So like to change something in a dental school, it's going to take like 20 years.

[00:28:39] I mean, we're just getting, yeah.

[00:28:41] We're just going to get rid of using Dicalf or like pulp caps and we're going to move.

[00:28:47] Wow.

[00:28:48] But yeah.

[00:28:49] Are you still using Copalite?

[00:28:51] Uh, uh, I have to say, I don't, I've heard of it.

[00:28:54] I don't even know what that is.

[00:28:55] So hopefully we don't use that.

[00:28:58] Uh, Nate doesn't have my gray hairs to know what Copalite is, Kevin.

[00:29:02] So yeah.

[00:29:03] Yeah.

[00:29:03] That's funny.

[00:29:04] All right.

[00:29:04] Uh, all right, Kevin.

[00:29:06] Uh, we got, we let Nate weigh in on, on, on lays.

[00:29:09] You're, you're the Sarah guy who doesn't on lays.

[00:29:12] Let's hear your story.

[00:29:13] Let's.

[00:29:13] It does not.

[00:29:14] So yes, that's what I said.

[00:29:15] Does not.

[00:29:16] Yes.

[00:29:16] So, um, I'm not anti on lay at all.

[00:29:20] And Steve Schiffenhaus and some of those guys on, um, keeps Eric.

[00:29:25] They're just brilliant.

[00:29:27] And, um, you know, I, I think that it definitely has its place, but this is definitely a in my

[00:29:34] hands sort of thing.

[00:29:36] So when I first got the Sarah and I saw all these sort of preps and everything, I'm like,

[00:29:41] I'm going to do that.

[00:29:42] Cause I thought I was preserving tooth structure and all that sort of stuff.

[00:29:46] Right.

[00:29:46] And I did that for a while.

[00:29:49] And the two things that have become problematic for me are the high and dry margin over a long

[00:29:57] period of time.

[00:29:58] Now remember I've been in the same place for 33 years.

[00:30:01] You start to get a discrepancy between the Emax and the natural tooth.

[00:30:07] And often in, at least in my case, you get like a, a stain line.

[00:30:14] And so the Emax is never going to change or, you know, pick up discoloration and the natural

[00:30:20] tooth is.

[00:30:21] So I've got a lot of two toned teeth out there, which if that doesn't bother the patient, that's

[00:30:28] fine.

[00:30:29] Um, that doesn't bother me as much, but I did get a lot of D bonds.

[00:30:34] So I just went back full circle to, um, uh, Schillenberg.

[00:30:40] I had to throw that out there, uh, just to, um, yeah, just to, um, I just think I can, I

[00:30:51] can get a better result with a full crown.

[00:30:54] However, I am leaving my margins, you know, a half millimeter or a millimeter super gingival

[00:31:01] on purpose, uh, because I do believe that, um, allowing the natural biology of the interface

[00:31:11] between a natural tooth and, you know, the periodontium is, is the best thing.

[00:31:17] If that makes sense.

[00:31:18] Sure.

[00:31:19] Yeah.

[00:31:19] So sure.

[00:31:20] Anyway.

[00:31:21] Sure.

[00:31:21] Makes it easier to scan.

[00:31:23] Yeah.

[00:31:23] Yeah.

[00:31:24] I, you know, the prime scan, I don't have a lot of trouble.

[00:31:28] Uh, the only trouble I do have, uh, like this happened yesterday.

[00:31:32] Um, so this is a case where, uh, a guy broke off the lingual cusp of number 19, but there

[00:31:40] was a bunch of decay on the buckle.

[00:31:42] Right.

[00:31:43] So I'm just going to do a full crown there anyway.

[00:31:45] And it wasn't a difficult scan, but it was a little bit difficult for my newest assist,

[00:31:51] newest, newest assistant to draw that margin.

[00:31:54] So I had to, you know, come in and, and, uh, oversee that.

[00:31:58] But, um, a fit was fine in the end, but you know, that, um, certainly leaving everything

[00:32:06] super gingival, anyone can read those margins.

[00:32:09] So it does make it way easier.

[00:32:12] I mean, when I look at those, those, uh, crown lays on like, you know, an Instagram, I do think

[00:32:20] to myself, you know, sometimes, especially when you're in the, uh, zirconia or PFM and

[00:32:27] looting game.

[00:32:28] Yeah.

[00:32:29] Now you're trying to get, you want all the tooth, you know, you want all the wall length

[00:32:33] you can get to keep that tooth on.

[00:32:37] I do think sometimes I'm like, wow, I'm really going to, boy, it's time to get out the laser.

[00:32:41] We're, we're hacking gums.

[00:32:42] We're, we're, we're prepping deep.

[00:32:44] Cause we gotta, we gotta capture that.

[00:32:46] We gotta capture wall length.

[00:32:47] And I do think that it's, I can see where it's a cleaner design to do what you guys are

[00:32:53] doing for sure.

[00:32:56] I've just been always hesitant of breakage on those in, on second molar situations.

[00:33:03] Um, are those, but I will say like you started off Zach, I've got a couple gold onlays from

[00:33:09] two thousands or late nineties that I plonked on with some cement and I probably didn't even

[00:33:17] keep it dry enough cause I didn't know any better back then.

[00:33:20] And they're still there.

[00:33:21] So there's some, there's definitely some bonus to that.

[00:33:26] I, yeah, I, the end of the day, I guess it's whatever, whatever works in, in your hands,

[00:33:32] but it is a neat idea.

[00:33:34] I do like it.

[00:33:36] And it's certainly something that I should probably consider, you know,

[00:33:40] You're right.

[00:33:41] The, um, the, I felt like my prep has gotten to be the same or probably faster than my crown

[00:33:49] appointment prep is.

[00:33:51] Uh, but delivery is longer.

[00:33:53] I mean, delivery is cause I'm bonding.

[00:33:56] So I've got to keep things isolated.

[00:33:58] Uh, um, but now I'm just so used to it.

[00:34:02] I've been doing, I mean, it's funny.

[00:34:04] I remember hearing this Instagram live, I think it was like Miguel Ortiz and Marcus Blatt was

[00:34:10] talking about and their topic of the conversation was, is the full coverage crown dead?

[00:34:13] And I was like, ha ha ha.

[00:34:15] Like now I, I majority of my, of my posterior restorations that are indirect are onlays.

[00:34:26] Like, like not just not like 60%, I would say like 75 to 80%.

[00:34:31] Like I'm doing mostly crowns to replace crowns, which I kind of had that idea going into it.

[00:34:37] But now I just like, it's hard for me to look at a tooth.

[00:34:39] And I can sometimes see when I'm looking at a tooth and like, depending on where the

[00:34:44] decay is or where the previous restoration is, I'm like, man, if I took out the previous

[00:34:49] restoration and then I prep the outside walls of the tooth, there'd be nothing left because

[00:34:53] like the only, like, like the best parts of the tooth are the outside.

[00:34:57] The inside has been replaced by this large album.

[00:35:00] So it's like, I just have like a core buildup of some composite and then a ceramic over it.

[00:35:06] Like, I don't know, like when I do that on my, I'm processing more tooth.

[00:35:09] That's the exact scenario where I've, I've thought about sometimes, especially with some

[00:35:13] of the endodontically treated teeth where it's like, okay, the outside's hogged out.

[00:35:18] Yeah.

[00:35:19] And now I got to take away, you know, I got to take something away around so I can, it's

[00:35:25] like, wow, what is this?

[00:35:26] What is this being supported by?

[00:35:28] And it feels like the next step is snap off of the gum line, which we all see.

[00:35:32] And then that's, yeah, I think that that is definitely an exception to what I'm, what

[00:35:39] I'm doing.

[00:35:39] If we have a endodontically treated tooth, I'm looking for, I want my onlay to fail before

[00:35:45] the tooth does.

[00:35:46] So I, I'm opposed to, you know, bringing my margin down to the gingiva on those if, if

[00:35:53] the scenario is correct.

[00:35:55] So that is one area where I will, you know, go back to my old ways for sure.

[00:36:00] And in that, in that endodontically treated tooth situation, you know, now me as the,

[00:36:06] as the person who's prepping a full, full prep and looting now it's like, well, I got

[00:36:11] to put a post in there because otherwise there is nothing in between there.

[00:36:14] Whereas if you're doing it your way, you really probably don't need that.

[00:36:17] You don't need that kind of stuff because you don't need, you don't need the center to

[00:36:22] be this strong retentive, you know, entity for your restoration.

[00:36:27] So it's definitely something to definitely, it's, it's, it's always one of those things.

[00:36:34] Everything ought to be on the table to do the best job.

[00:36:37] And yeah, I think it's definitely a tool you need in your toolbox.

[00:36:40] Yeah.

[00:36:41] Yeah.

[00:36:41] For sure.

[00:36:42] Absolutely.

[00:36:43] Well, Nate, any final thoughts on onlays, crown lays?

[00:36:50] Um, no, not too much.

[00:36:52] I think that, uh, you know, that, that, uh, my, my part that we've done is, um, uh, that

[00:37:01] I felt like one of the biggest helps was doing figuring out about that teleo onlays, figuring

[00:37:05] out how to temporize them.

[00:37:06] Cause that was the hard part is, you know, we'll try to put a link to that in the, in

[00:37:11] the notes.

[00:37:12] Teleo onlays.

[00:37:14] Um, when, do you know what, like, if someone was going to go to Densal tube, do you know

[00:37:20] what kind of month you were posting about onlays in so they can scroll back?

[00:37:24] Do you have a, you have any, any idea?

[00:37:26] Like when you were posting about stuff?

[00:37:28] We posted a lot about onlays.

[00:37:30] Honestly, you know, better than going to us, uh, that Marcus Blass, like he, like just

[00:37:36] in like November, maybe he was posting a lot about onlays.

[00:37:41] I think in December he was posting about treating endodontically treated teeth and he's

[00:37:46] really, he's really covered the topic pretty thoroughly.

[00:37:50] So, and he's, he's referencing a lot of work from Marco Ferrari, who is a guy that

[00:37:55] published these, I think they're available for free and get on the internet.

[00:37:58] Some, you know, they're, they're articles, but they're not like the nerdy articles that

[00:38:03] no one wants to read.

[00:38:04] They're more like articles that kind of show different prep designs of like, you know,

[00:38:09] what do you do if you want to maybe just preserve one marginal ridge?

[00:38:12] So it shows a prep design where you, you kind of preserve the marginal ridge, but you still

[00:38:17] cover the entire physical surface and it shows all these kinds of neat things that you think

[00:38:21] about when you're doing these online preps.

[00:38:23] So, um, so yeah, ours, the stuff we posted about onlays was like in the pandemic.

[00:38:28] So it was pretty old, but the blast stuff is he posted that 2022 back then.

[00:38:34] Okay.

[00:38:35] Right on.

[00:38:36] Kevin, any final, final thoughts on onlays for the week?

[00:38:40] Rock on with your onlays.

[00:38:41] All right.

[00:38:42] Well, I think you've, uh, you've, you've caused me to think about it and I'm gonna have to

[00:38:46] become an onlay fan.

[00:38:47] So onlay.

[00:38:48] Oh, that was brilliant.

[00:38:52] That's the title.

[00:38:53] Onlay fans.

[00:38:54] Yep.

[00:38:54] Oh, onlay fans.

[00:38:56] Oh, nice.

[00:38:58] Get it now.

[00:38:58] Thank you guys, uh, for listening.

[00:39:00] Uh, and we will catch you on next Tuesday's show.

[00:39:03] We will bring in Nate back.

[00:39:05] See ya.

[00:39:06] See ya.