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Dental Tribune MEA had the pleasure to talk to Prof Lorenzo Breschi from Italy about minimally invasive dentistry and trends in the dental industry.
Would you give us an introduction to yourself, your practice and your experience?
My name is Lorenzo Breschi. I’m head of restorative dentistry at the University of Bologna, and I’m a university lecturer, so I have the privilege of working with students and teaching them restorative dentistry, conservative and fixed prosthodontics, and I’m a private practitioner. I try to manage both the teaching part and clinical practice of restorative dentistry.
You’re well known across the world for your minimally invasive dentistry and that’s the reason you are here at the trade show in Dubai, UAE. What are the techniques and the tools that you use that have made you so successful, and could you maybe give us some tips and tricks?
My main topic has always been bonding, so I’ve seen the bonding revolution since the start. I’ve had the privilege of working with many giants of this field, starting from Jean-Francois Roulet, and I’ve also had the privilege of serving as the associate editor of the Journal of Adhesive Dentistry, so I work also on the research side. I believe that adhesion has changed the way we do and manage dentistry, starting from an extension of prevention to what we do today, which is prevention of extension, but I think it’s a revolution not only for us as dentists but also particularly for patients. Nowadays, patients can really understand many of the clinical treatments we are doing and why we do it, thanks to digital dentistry and the possibility to simulate all the steps and the final outcome of our dental treatment. The new materials that have been launched on the market in recent years dramatically changed the way we do dentistry, and this is something that we must keep in mind. Shifting from metals to ceramics and composites definitely changed not only the mind of the dentist only but also that of the patient and his or her willingness to go to the dentist, along with other important aspects, including aesthetics. The aesthetic requirements today are very high. Bleaching, for example, is a crucial aspect in this regard. Adhesion, bleaching and new materials are the three things or aspects which in my opinion completely changed the way we do dentistry today.
We are here today at the Ultradent booth. Can you tell us a little bit about the new generation of the one-shade composite?
This is indeed the future. We’ve been through simplification processes in the last few years. Regarding adhesive systems, we simplified from the three steps to the one step. We simplified luting materials, and we simplified composites. Having the possibility of using a single-shade material is a great advantage because this allows us to work easier, faster and smarter. Furthermore, it enables us better control of the material and its expiration date because we can reduce the number of syringes that we need to keep in our office. Interestingly, while the very first versions were probably not effective from an aesthetic point of view, today’s versions are indeed excellent in reproducing the colour match, the opacity, and viscosity and handling of these materials have been improved. In particular, I have had the privilege of working hands-on here with FORMA. By using this material, you can really observe an excellent result in terms of aesthetics that can be achieved by simplification and application of only one material. The technique of placing an entire composite restoration in a single-shade material is very effective, particularly for posterior teeth. Of course in the anterior region you may use additional effects if you have a single incisor with specific requirements seen in young patients. However, for an older patient, for example, with layers that are more opaque, this single-shade material is highly indicated also in the anterior region, so I think it can be used in more than 95% of clinical cases with excellent results. The same results are achieved with multi-shade materials, so this is indeed a great simplification of our daily work.
Let’s talk a little about the course that you gave here. What was it on?
The course was about minimal intervention, and we went through minimal restorative procedures and how to use dental adhesive systems and how to use single-shade composites, such as FORMA. The idea was also to look at the state of the art from a theoretical point of view as well as work hands-on on a Class II restoration on simulators, and it was very effective. I had the privilege of working with 20 participants from all over the Middle East, so it was an excellent situation in which we had the opportunity to exchange ideas and interact. It’s wonderful also from my side to see different techniques, opinions and ways of doing things.
What was the feedback from the participants?
The feedback was great. We had a wonderful talk. People here are always smiling and happy, way more friendly than one might expect, and hungry for education, but they start already from a very high level of education. You see that they have specific bases for everything, because they pose the right questions at the right time, so they know what they are talking about. They know the properties of the materials and how to use them and they have excellent handling ability.
Why is photopolymerization so important?
This is a crucial aspect that we have under-estimated for years. We have to start from one critical point. There are no over-cured composites in the mouth. In fact, all the materials we’ve used in the mouth are under-cured. The materials we use have a curing degree of approximately 60% to 64%, and this is way lower than what we would expect in order to achieve the best mechanical properties. What are the key aspects of this? The very first important aspect is the curing lamp, and the dentist must invest in this. The lamp must be poly-wave. In other words, it’s very important to have a lamp that delivers not only blue light but also violet light. Why is this important? Because we know that many new materials today, particularly super-white ones, used for bleached teeth, do not contain camphorquinone but contain other initiators, and these hydrophilic new initiators, such as Lucirin TPO, are not activated by blue, but by violet light. We need a light that delivers not only 460 nm, as we are used to, but also 395 nm, which is violet to purple. It’s important to use lamps such as VALO. VALO is an excellent light curing unit because it has three LEDs which deliver blue light and a fourth LED which delivers violet light. This is very important so that the final outcome of the light is not only centred on the blue but is centred on a poly wave. This is crucial, particularly for self-adhesive cements, the new universal adhesives and the new composites that are very white. We know that camphorquinone is yellow, so if we add a lot of camphorquinone, these composites become yellowish, and so these materials need something different to be activated. Indeed, we have under-estimated these aspects for many years. The dentist typically invests a lot of money in buying a handpiece, loupes and expensive equipment, like for CAD/CAM and microscopes. This should be the case for the curing lamp too.
How long have you been using VALO for?
I think since it was launched in 2009.
What is your opinion of the new cheek retractor, the Umbrella?
I use it and recommend it. It’s particularly useful for bleaching procedures and anterior restorations in which dental dam isolation might be challenging, as well as for Class V. It has important advantages with respect to other similar devices, namely tongue and cheek retraction. The ability to keep the tongue low in the mouth and the cheeks retracted in the lower and upper jaw areas allows the dentist to work in a very dry environment. This is particularly important for in-office bleaching procedures and Class V restorations. For direct restorations, however, I prefer using a dental dam, but I know that some dentists are not familiar with its use, so this is another great tool to achieve dry dentistry, which is a fundamental pillar of adhesive dentistry; we have to have an adequate isolation of the working field.
What about the dental industry? Where do you see the next five to ten years in relation to the products now released? What are you missing as a clinician? What do you think could be even further improved?
Being a restorative dentist, I must say the materials. I think that we could have biologically active materials; in other words, materials that will not only be used as replacement of tooth substance, but smart materials that will allow healing of carious tissue or that could reduce microbial contamination. This is indeed another crucial aspect. We know that the material will not last in the mouth forever. We know that retreatment is a large part of our work, and patients would like to reduce that. Having smart materials that could decrease, for example, bacterial contamination may be a way to achieve bond and restoration longevity over time.
Simplification is what a dentist requires, so in the short term I would say that we need simple materials and a simple way to use them. In the long term, I’d say smart materials that are biologically active to the benefit of patients’ oral health.
What is the longest-lasting restoration in one of your patients?
Some that I did when I just graduated, so more than 20 years. Another key important factor that we haven’t spoken about is the operator. We know that the operator in adhesive dentistry is crucial. Besides using excellent materials, you need to use your hands in the proper way and you have to follow strict protocols and stay focused on the timing and on the details. We know that these techniques either work or they don’t work. There is no middle ground. For bonding, it’s well known that you do the procedure properly and you get excellent bonding or if you make a little mistake it will fail, so it’s either a good bond or zero bond. This is true for many aesthetically demanding situations and procedures: either you do them well or the result is a catastrophe.
Do you have any final advice for dentists in the Middle East?
I’d advise them to stay up to date on their education, for example by taking CAPP’s courses.
Thank you very much for your time.