Episode #376: Tips For Anterior Composites, with Dr. Marcos Vargas

 Patients are aesthetically driven more than ever. But aesthetics is beyond just the tooth itself or what the patient wants. And to share tips on how to have these discussions with patients, Kirk Behrendt brings in Dr. Marcos Vargas, a professor in the Department of Family Dentistry at the University of Iowa. With his advice, you will think differently about aesthetics and anterior composites, and learn why composites are vital to your practice. To learn how to make your patients happy with your composites, listen to Episode 376 of The Best Practices Show!

Main Takeaways:

• Aesthetics is not just about the tooth itself, but the entire face.
• Never give the mirror to the patient! And keep it at your arm’s length away.
• The “perfect” smile is different for each person.
• Avoid patients who you can't make happy with your dentistry.
• If you want to learn aesthetics, learn dental anatomy.

Quotes:

• “Anterior composites are one of those materials [that], with the proper techniques, [can] really save tooth structure. It’s just so conservative, the nature of it. Preparations are minimal, if needed. I think dentistry is moving in that direction, conservative dentistry. We’ve been moving for a while, and that movement has accelerated. So, I think everybody needs to know composites. When you tell your patient you are going to do something very conservative, they immediately perk up and say, ‘Oh, I like that,’ because probably from their physicians and medicine care, since I'm getting more conservative — like surgeries are getting much smaller, getting into robotics and things like that, they know that minimally invasive is better. So, that trend is catching up in dentistry too.” (8:26—9:17)
• “Patients know. It’s like, ‘Oh, conservative. You want to save my tooth or my tooth structure. That's great.’ So, I think nowadays, we should be looking into providing that care to our patients, minimally invasive care, preventive care, in all aspects.” (9:18—9:37)
• “Always think about the face, the smile, and then the teeth from the outside to the inside. The face frames the lips, the lips frame the teeth, and the teeth are framed not only by the lips but also by the gingiva.” (12:01—12:15)
• “In the past, we looked at just the teeth. We just looked at the teeth, and the rest wasn't that important. But patients come to you for aesthetics. And aesthetics is not on the tooth itself, it’s in how all the teeth fit together, the centrals, the laterals, the canines, the premolars and the buccal arch, how they fit together, where they are with respect to the gingiva, how the gingiva comes down, how the lips move when the patient smiles, how they show it, how their lips move and show the teeth, and how that smile fits on the face. So, that's how I think somebody that is new to dentistry needs to look into it, from the face in.” (12:22—13:02)
• “Usually, a patient will come with a very specific — aesthetics can be small, it can be big. So, let me give you a couple of scenarios. One is when the patient knows very specifically what they do not like. Example, ‘I do not like the space between my front two teeth.’ Or somebody can say, ‘I don't like my smile.’ So, very different. And the diastema between the two front teeth is very specific. So, they already know exactly what they're coming for to the office. And on the other side, you have the people that have these, ‘I want to have a better smile.’ So, it’s a very different approach that I have.” (13:50—14:36)
• “Usually, the patients that have a small diastema, I would probably grab a little composite, put it in the mouth, just muck it up, three-second cure, give them the mirror. Now, let's do a little parentheses, because I think that's a tip that I want to give you there, the mirror. I learned a long time ago, never, ever give the mirror to the patient. Always hold it for them at an arm’s distance. And it’s your arm distance, not the patient’s. Because you know what they do, right? They immediately grab the mirror, put it this close, like about an inch from their face, and start looking at it. And you want to keep showing from afar. Why? Because, again, the aesthetics is from the face to the lips to the teeth. You want them to see their face, not specifically their teeth. So, never, ever give the mirror to the patient, ever.” (14:37—15:31)
• “We have the conversation [with patients], what are the pros of veneers, what are the pros of composite, and I tell them, ‘Conservative. I don't have to remove your tooth.’ Cost, longevity, we discuss all those things with the patient. And the patient makes up their mind which one they want. Also, we need to think about the patient’s habits. Smokers, heavy coffee drinkers, wine drinkers — composite is not going to last that long. So, based on that information I have from the patient, I may make a suggestion, ‘Well, because you are a heavy smoker, wine drinker, I might steer you to porcelain. Even though porcelain, I might have to reduce a little bit of your teeth, I think longevity, in your case, that's the way I want to go.’ Or, ‘Well, you don't drink coffee. You are very good with your hygiene. You don't smoke. I think resin probably would be a better alternative for you.’” (16:19—17:13)
• “When I lecture to my students, I say, ‘Let's think about the material we’re choosing here. And we choose based on aesthetics and function.’ So, in that case that I told you, the diastema, we’re looking at a situation, and probably the occlusion is a normal occlusion, no parafunction, nice balance, and then the composite would last for a very long time. Now, I have to balance my aesthetics with the function. If I have a patient that, a lot of parafunction, you see wear facets, and you might have to tell the patient that they need rehabilitation or a mouth guard, they haven't gone there, well, I don't want to do composite because my composites are weaker than my ceramics. So, I have to have that in account. I have to account for function. It’s so important.” (17:50—18:39)
• “Let's talk about the other case [where a patient says], ‘I don't know what I don't like about my smile.’ I think, as humans, we always think about what is the “perfect” smile, right? But the perfect smile is different for everybody because everybody has different gums, different lips, and different faces. So, that's what I mentioned before, everything comes from the face in. So, I will take photographs of that patient and say, ‘Well, let me see what I can do in your particular case to give you maybe the smile that you want to have.’ So, I will take a series of photographs, the face, the face at repose, smiling, forced smile, and start looking at lip mobility, things like that. I will take models, and maybe a couple of scans, upper and lower scans, the bite, put them in the computer, trace some lines that I think is going to be good, kind of like a digital smile analysis. I do that a lot.” (19:51—20:53)
• “Global diagnosis, it’s right there up top with anything that is aesthetics. So, back in the computer, I trace some lines, go and do a digital wax-up, maybe do a printout and do a mockup in the patient’s mouth to gauge what I think, in that face, fits good. So, I do the mockup, and then I show them the mirror, far away, or do a video, something like that. And then, I gauge how they like what I think is going to fit their mouth and their face. And I will say nine out of ten, or even 19 out of 20 people, it’s like, ‘Oh my god! I didn't know I could look like this!’ And then, you tell them, ‘For this, to get to where [you want], we might need to do ortho. We might need to do perio, meaning move your teeth, move your gums, do crowns, composites, porcelain veneers, to get you here. And this is the plan that I have for you if you want to get here.’ And a lot of people go that route.” (21:10—22:17)
• “Unfortunately, there is that one out of 20 that look at it, even though you show them with the mirror far away, they look at you like, ‘Eh, I don't know. I don't know if that's what I want.’ I'm going to tell everybody, those are the [patients] that you want to stay away from. Immediately, if your mockup that you think fits good in those lips, in that face, and they don't like it, I say to them, ‘Yes, obviously, I'm not making you happy. So, maybe my knowledge is not as high for the requirements that you are asking me to do. Maybe I'm not the dentist for you.’ And, believe me, when I have those patients, they say, ‘Thank you very much for letting me know that. Where do you recommend me to go?’ And I say, ‘I don't recommend anybody.’” (22:18—23:13)
• “If I'm thinking that 19 out of 20 times or 18 out of 20 times the patient is going to accept my treatment, I don't charge for that digital smile design, that prototype, that blueprint, because it helps me, and it’s going to be incorporated in the cost of the treatment. So, I don't charge for that. And also, at the same time, it helps me to eliminate that one or two who don't want treatment, or I won't be able to make happy, because I don't want to go that route. That's a nightmare. So, that's what I do.” (24:19—24:52)
• “When I'm done, I don't want to ask the patient, ‘What do you think? Is it too square?’ I don't necessarily go that way, because once you're asking those questions, that's when you have to give them the mirror, and they put the mirror this close. So, I don't go there. We try not to go there. I build it up to the best of my abilities. It looks good to me.” (30:46—31:08)
• “Another tip for the young dentist that really wants to learn aesthetics: learn dental anatomy. Learn dental anatomy. That's line angles, everything that you have to know. Because when you are doing direct composites, that's what is going to make the difference between you and somebody else, the anatomy, the finesse you have when you are building those teeth, and the finishing and polishing. That, to me, is another tip. Learn dental anatomy.” (31:14—31:42)
• “Everything that is aesthetics, [patients] want it. They want it now. So, learn composites, because it’s going to be a tool in your armamentarium that is going to save you, that is going to make your patients happy, and that is going to make your practice thrive.” (33:51—34:07)

Snippets:

• 0:00 Introduction.
• 4:34 Dr. Vargas’s background.
• 8:04 Why this is an important topic.
• 9:38 Materials and techniques are better today.
• 11:30 How to approach anterior aesthetics.
• 13:30 How to talk to patients about anterior composites.
• 17:13 Balance function and aesthetics.
• 18:46 How to talk to patients who don't know what they want.
• 23:29 The time it takes for each visit.
• 26:33 The treatment planning process.
• 28:40 Treatment tips.
• 30:12 Learn dental anatomy.
• 33:10 Last thoughts.
• 35:41 What Dr. Vargas does and his contact information.

Reach Out to Dr. Vargas:

Hands-OnLine website: https://www.handsonlinelive.com/

Dr. Vargas’s Facebook: https://www.facebook.com/marcos.vargas.1963

Dr. Vargas’s social media: @marcosvargas999

Resources:

ACT Dental To The Top Study Club: https://www.actdental.com/ttt

Seattle Study Club: https://seattlestudyclub.com/

Rocky Mountain Dental Convention: https://rmdconline.com/

California Dental Association: https://www.cda.org/

Phelan Dental Seminars: https://phelandentalseminars.com/cmo-posterior-webinar

Dr. Marcos Vargas Bio:

Dr. Marcos Vargas attended Cayetano Heredia University School of Dentistry in Lima, Peru and graduated in 1985. He spent two years, 1990 to 1992, in the AEGD program at the Eastman Dental Center in Rochester, New York. Dr. Vargas received his Certificate and Master’s Degree in Operative Dentistry in 1994 at the University of Iowa where he is currently a Professor in the Department of Family Dentistry. His primary research interests are in the areas of dental materials including glass ionomers, dentin bonding, composite resins, and esthetic dentistry. Dr. Vargas is also recognized for his expertise of Direct Restorative Treatment Procedures and conducts numerous lectures and hands-on seminars in the U.S. and internationally. Dr. Vargas has published extensively in the areas of dental adhesion and resin composites for over 25 years. He maintains a private practice limited to operative dentistry with an emphasis on esthetic dentistry.