Digital workflows are becoming more and more popular, but what happens when the results aren’t perfect? Today, Kirk Behrendt brings on Dr. Dennis Hartlieb, an expert in cosmetic dentistry, to explain why freehand direct composites are still important in an increasingly digital world. To find out how freehand direct composites can help you have happier patients and more satisfaction in your practice, listen to Episode 603 of The Best Practices Show!
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Links Mentioned in This Episode:
Dr. Christian Coachman’s Digital Smile Design.
Learn more about Dental Online Training.
Listen to the DOT Sharecast podcast.
Join the DOT Study Club.
Composite is a first-rate material, but it’s not as strong as porcelain.
Digital dentistry isn’t perfect, so you need to be able to use your hands.
Differentiate yourself from your competition.
Composite veneers are more fixable than porcelain.
When it comes to doing a direct composite veneer, contour is king.
Find satisfaction in your work.
“There’s great materials in dentistry, and composite is not a second-rate material at all.” (06:31—06:36)
“The reality is, and I’ve done enough of this interplay between digital and analog, there are times when you have your digital, you bring it to the mouth, and it’s not quite what you thought it was going to be. Also, there’s a can’t that you weren’t anticipating, even though you did everything that you thought was right. Maybe the teeth are too long, maybe the teeth are too short. Even though you use your digital smile design, that’s not exactly what you thought it would be. So it’s incumbent that as dentists, we still recognize that we have to use our hands. You know, this is what we’re about. We still need to be able to use our hands. And for me, freehand composites mean the ability to be able to layer composites, place composites, be able to contour composites and polish composites by hand to create the shape and the texture and the contour and the form that we want and that we need. And while I think it’s fine and great to be able to use guides to help us along, I think ultimately, if we’re just going to be dependent on a digital workflow, there’s going to be times when you’re going to fall short and you’re going to need to have the skills to be able to meet the expectations of the patients or maybe meet your own expectations of what you want the smile to look like or want a particular tooth to look like.” (14:55—16:05)
“There’s going to be, I can tell you, continued break between types of dental practices. You’re going to have the practices are going to be doing more boutique type dentistry. There is going to be more of a competitive demand where you’re competing against DSOs for more general and maybe traditional practice. So when you get into these boutique practice, you have two differentiate yourself. Part of it is the dentistry you’re going to deliver. But part of it is also sort of the artistic view the patient has of you. And so, I mean, patients typically like every week, patients are saying, ‘Oh, Dr. Lieber’s such an artist,’ and I’m not. I mean, if you ever saw me draw, you know, I’m not an artist, but I do know how to make teeth look like teeth, or I know how to make composite, or I know how to make acrylic, or, you know, porcelain. I know how to make those look like teeth. That’s a skill that I think brings patients into my practice. That’s what differentiates my practice from other dentists in my community, is that I’m recognized as being this artist dentist.” (16:30—17:33)
“When I talk to patients and we’re talking about cosmetic dentistry, I tell them you have two options when we’re looking at materials: we can do plastic or we can do glass. Okay, so glass is going to be porcelain. I’ll tell patients ‘You’re probably familiar with porcelain veneers, you may have friends who’ve had them or maybe a porcelain crown.’ And I’ll explain the technique. You know, dentist’s going to drill the tooth. I’m going to take an impression either with the putty material or digital material, whatever. We’re going to take an impression, we’re going to send it to a laboratory, or we’ll mill it here at the office, but it’s going to be a hunk of porcelain that gets glued on your tooth—but we have to drill your tooth to do this. With the other material, composite or bonding or what you might want to think of as more of plastic material, very often I have to do no joint at all in your teeth. And if I do have to do drilling, it’s going to be a lot less than if I have to do porcelain.” (18:48—19:34)
“When I’m talking to patients, I say ‘One of the things you have to decide is, “Are you someone who wants the least amount of tooth structure removed from your tooth, or are you looking for the greatest longevity of the material?”’ Because that’s going to be the biggest difference between porcelain and composite. Porcelain is going to give you the longest, most likely the highest longevity. Composites, it’s going to most likely give you the least amount of tooth structure removed. We can make both of them look beautiful. What’s in it for you? The advantage of composite, I tell them also is it’s immediate. We do it, we’re done. If we don’t like it, we can change it. When I do porcelain, once it’s on, it’s on. And if we’re going to change it, we’ve got to drill it all off. We’re going to start from the beginning, and I’ve done that too many times in my career, man. And I hate it. And I tell you, on any given day, on any given day, I’d rather do composite veneers 100% over porcelain veneers any given day. (19:35—20:27)
“[I’d rather do composite veneers] because if patients aren’t happy, I can fix it. I can change it. And if ultimately, because I do so much minimal to no preparation, I’ve had a couple of cases where I’ve taken it right off and give them their teeth back.” (20:29—20:41)
“It gives you that chance to get out, because once you put a burr on people’s teeth, man, you’re married to them and they own you, man. It’s tough.” (21:10—21:16)
“The better you get at this, than the more challenging the patients you’re going to attract.” (22:06—22:11)
“I love my labs, and I’m blessed to work with some really very, very talented people. But number one is the cost factor. And that’s something I talk to patients about. You know, if you’re going to do this in porcelain, this is my fee plus the lab fee. So my fee for a porcelain veneer is the same as my fee for a composite veneer, except add the lab fee to the porcelain veneer.” (22:45—23:04)
“I have to explain to the patients, I say, ‘Look, my lab costs are variable. I’m not quite sure what the lab is going to charge me for doing a single and central incisor. We’re going to do a single tooth and the fee may be 2 to 3 times, right? If they if they have to make their crown five times to get it to look great, there’s going to be an additional cost. So that cost is on you. I’m going to be eating my costs on how many times I have to try it in, but I have to have my costs. I have to have my fee structure to support my dentistry.’” (24:20—24:49)
“In the composite world, I think it’s really just about executing at a higher level and just getting better at it. I’m not seeing anything that’s going to be revolutionary, that’s going to be changing the way we’re doing composites. I think essentially, we’re just getting better at understanding how to handle the materials and how to make everything look natural.” (25:54—26:11)
“I tell patients this all the time, if my composites were as strong as porcelain, I would never use porcelain again. The reality, though, is that there’s going to be advantages with the strength of porcelain. But I think that our composite materials will get stronger, and I think that’s where we have issues. Just the flexural toughness of composites.” (26:56—26:16)
“This is what you’ve got to figure out, is where do you want to be in 30 years? Dentistry is hard, man. I tell you, doing clinical dentistry is tough. Now, I’m better at it, but it’s still hard. You know, working on tooth number two. Forget them. It’s hard, right? Working on, you know, distal number two, Distal number 15, you know, tongue is in the way—dentistry is hard. Managing patients sometimes is difficult. Managing teams, you know, can be challenging. So I would say for the young dentist is, ‘Where do you want to be, what type of dentistry do you want to be doing 30 years from now? When you retire, what do you want to be looking back at? Do you want to be looking back and saying, “I’ve been able to do some really awesome dentistry?” Or do you want to say that, “Look, I’ve been able to, you know, accumulate this kind of wealth and I, you know, the type of dentistry I’m doing doesn’t matter.” Then just grind it out and that’s cool. But if the type of dentistry does matter, then I think you got to set your compass.’” (29:03—29:59)
“You don’t have to rely on lab technicians, you don’t have a lab bill, your material cost is very low. You’re really only expense is learning—it’s the education on being able to do that. But once you’ve invested in yourself beyond the fact that you’re able to satisfy so many other patients, it’s not like it’s just a one for one, you’re paying a lab bill and you’re getting this. When you’re learning, you’re growing and it’s going to be more enjoyable. You’re going to love the experience more. You’re going to draw a different type of audience into your practice as you develop these skills. It’s going to be more enjoyable. Your team is going to enjoy it more. They’re going to be applauding the dentistry you’re going to do because you’re going to be changing people’s lives in a way that you’re not going to if you’re just going to be doing, I think, you know, sort of the bread and butter and PPO-type stuff.” (31:29—32:19)
“I think the two biggest mistakes or failures to understand is contour is king. I don’t care what composite you’re using, I don’t care if you’re off by a shade, it is contour is king. You have to learn contour. And unfortunately, it’s the hardest part, I think. I think layering is difficult, but contouring is the hardest part. It’s what takes me the longest when I’m doing a direct composite, like a direct composite veneer, contouring is king. And then second, I think there’s the polish in the surface texture, surface finish. I think that’s the two keys. The third is learning how to block out so that you don’t get shine through with your composites.” (32:40—33:19)
“I believe we have to have satisfaction in what we’re doing in our service. As we serve others, I think we make sure that we are serving ourselves as well, making sure that we have satisfaction that we love what we’re doing. And not every day is great, you know, sometimes you’re like, ‘Oh God, that did not come out the way I was thinking it was going to come out.’ But, you know, you go every day, you know, you get 1% better. You just keep on trying, try and get a little bit better, try and get a little bit better. And evaluate your work and just be truthful and be honest with yourself.” (34:32—35:04)
“We’ve got to make a living, right, and we deserve to make a good living. We’ve worked hard, people are investing a ton in their education. We deserve to make a good living, but we also need to feel good about what we’re doing. We need to go home and say, ‘You know what, we are making people’s lives better.’ We’re servants and we’re doing great, but we’re getting this internal satisfaction as we’re making people feel better, too.” (36:09—36:32)
“I think in the digital world, if everything goes well, it’s awesome. But too many times and I mean, whether this is with implant surgery or if you’re doing composites. I mean, anyone who’s done, or they’ve brought their prototype provisionals to the mouth, and all of a sudden there’s a can’t they didn’t anticipate. Even though they thought they did the workflow correctly, something just went wrong. We have to have the hand skills to be able to make corrections. We have to develop those skills. I mean, this is still dentistry. We still have to have these hand skills. So as great as digital is, and I think it’s improved dentistry without question—it’s made it more efficient, I think there’s a lot of things we can do in the digital workplace that we’re not able to do so easily in analog—we still have to use our hands. So we have to spend the time, we’ve got to educate, get educated on how to do techniques better so that we can be even better at what we’re doing.” (36:48—37:41)
02:07 Dr. Hartlieb’s background.
07:40 Dr. Hartlieb’s trip to Spain.
10:28 Learning how to communicate what you’re doing.
13:42 What are freehand direct composites?
16:06 Find a way to differentiate yourself.
18:25 Differences between porcelain and composites.
21:17 The higher the fee, the higher the expectation.
22:17 Benefits of not working with a lab.
25:20 The state of composites.
27:40 Figure out what you want your future to look like.
32:19 What most dentists get wrong about direct composites.
33:49 Taking gratification from your work.
36:32 Last thoughts about freehand direct composites.
37:41 Dental Online Training.
Dr. Hartlieb Bio:
Dr. Dennis Hartlieb is a graduate of the University of Michigan School of Dentistry. He maintains a full-time practice, Chicago Beautiful Smiles, in the Chicago suburb of Glenview, Illinois. Dr. Hartlieb is an instructor at the Center for Esthetic Excellence in Chicago and is an Adjunct Associate Professor at the Marquette University School of Dentistry in Milwaukee, Wisconsin. He lectures extensively to dentists throughout the US on the art and science of anterior and posterior direct resin techniques. Dr. Hartlieb is an Accredited Member of the American Academy of Cosmetic Dentistry. He is also a member of the prestigious American Academy of Restorative Dentistry, and the American Dental Association. He is the president of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and officer for the Chicago Academy of Dental Research study club. His dentistry has been seen in many dental publications and he has contributed articles on his techniques in restorative dentistry.