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AUDIO - HSP #150 - JAN HAJTO
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In Europe, there is very little curriculum about aesthetic design rules of anterior teeth. Dr. Jan Hajtó shares some of the principles he's been studying for years.
Dr. Hajtó (1968) graduated from the University of Munich / Germany in 1993. Since 1995, Dr. Hajtó has been running a private practice in the heart of Munich and he specializes in aesthetic fixed prosthodontics and complex restorative dentistry. Dr. Hajtó’s clinical work includes all-ceramic restorations, complex aesthetic cases and implant crowns and bridges. He possesses many years of clinical experience in both conventionally cemented and adhesively bonded all-ceramic restorations.
Apart from his clinical activities, he is the author of numerous publications. He is both a nationally and internationally active lecturer in the field of dental aesthetics, all-ceramic restorations, CAD/CAM, digital dentistry and complex prosthodontic treatments. In addition, he is author of the book “Anteriores – Natural Beautiful Teeth”, Teamwork Media, published in June 2006. and the author of the chapter “Veneers” in Roland Frankenberger (ed.) Adhäsive Zahnheilkunde, Deutscher Ärzte-Verlag 2012.
Full mouth rehabilitations with implant/tooth-supported restorations
Porcelain Veneers and All-Ceramic restorations
Functional analysis and treatment of the stomatognathic system (TMD – Temporo-Mandibular Disorder treatments)
Howard: It is a huge honor today, at twelve noon in Phoenix Arizona to be interviewing, podcast interviewing Jan Hitow, Doctor Jan Hitow, an aesthetics cosmetic dentist legend in Munich Germany. It's now 9 pm there, thank you for ... are you staying up past your bedtime to do this, what is your natural bedtime in your life?
Jan: Midnight, or a little bit later.
Howard: Okay, so I'm not going to keep you over your bedtime, but Germany is known for Mercedes and Porsche and I've been there several times. My favorite dental meeting in the world is always in Calogne Germany, that's the IDS meeting, is it, IDS?
Jan: IDS, yeah.
Howard: What does that stand for? International Dental Show?
Howard: Show, yeah. It's absolutely the largest meeting in the world.
Jan: It is, yeah.
Howard: I think 110, 120,000 dentists show up. You could not see every booth if you were just walking at a brisk pace. You couldn't even walk by every booth, but you have to admit, Germany, it's got some of the greatest dental companies that ever existed, from Kabo, to Serona, to Ivanclaire. I count Ivanclaire, it's Lichtenstein, but wasn't Lichtenstein used to be part of Germany?
Howard: Lichtenstein was never part of Germany?
Jan: Lichtenstein actually was more a country of it's own, it always was. It still is, it has it's own, how do you say, it's not a king, but ...
Howard: You really can't tell, it's very much like Germany, you can't really tell you've left Germany and gone to Lichtenstein, would you say that's true, or is it very different to you?
Jan: Not from our perspective, I think for Americans maybe all Europe looks quite similar, everything is so close, but to us, Switzerland and Austria is definitely different from Germany. There's a talk difference, when you hear them, when they talk they talk completely different from us.
Howard: Let's start with your book, you just came out with a book called Interiors Natural Beautiful Teeth. What made you write a book on, what made you write that book?
Jan: Actually, I was always interested in art, already in school. So that was one of my fields, I also did my art school exam, so when I ... when with dentistry I somehow missed the creative part, and all these ... of creation. What I learned in dental school was repairing teeth and not creating.
We haven't been taught this in dental school at all, that was something, I think it's still not really an important part of our education here in Europe and Germany. Still there is no curriculum, all the teaching materials are not really structured, and at that time ... actually I wrote the book about fifteen years ago.
It was just now translated to English. Fifteen years ago there were not many books on this, if you wanted to teach yourself and then read about it. So, there was the book by Goldstein Gobber, and Sheesh, those were the two, and Rufanolf, these were the three books.
So, actually, I didn't want to write a book, I was interested to teach myself, so I started looking up all the literature that already exists, and I was really amazed to find how much there already was existing. Most of it came from the U. S. Diverse tablets, and different aspects of perception, how teeth form better, what makes teeth look natural or more harmonic, or more beautiful.
So, actually I did two books. First came the project, I cannot tell you where that came from, maybe that's how I think or I'm structured, somehow I realized that it will take a very long time if I want to learn about natural time if I do this over the years. Then I will see a few nice cases, maybe this month, maybe in three months, I connect them, so somehow I got the idea to do this faster.
Still I do things like that. If I'm really interested in something, I try to get an overview on it, and it's a lot of work to sit down and go through hundreds, or thousands of samples on something, but human perception is very good at recognizing patterns. We're not good at remembering what [inaudible 00:05:00] and what it looked like, but when you put something in front of you like 40 or 100 natural renditions as models or tooth shapes, then immediately you can recognize similarities or differences and characteristics.
So I placed an ad here in the local newspaper, and asked for tooth models. It was really funny who everybody came there, because there were teeth that were bronze or ... I wrote a natural easy teeth, and there were people ... and then I offered some money because I knew I want to have the rights on this material, I want to be able to use the pictures to do some models, I took impressions on those, so I think it was several hundred people who came to me and I looked at them, and I selected those who were really healthy and beautiful and natural perfect partitions.
Then I took one look for each patient, and took a four set of photographs, and impressions, and had them sign that I might use all this for digital and printed media, and that was a picture atlas that I had done, and that was done in half a year.
So that I had quite fast, that book, it's a black book, doesn't contain much text, it's just a catalog of beautiful teeth. That got very successful among dental technicians, because for them it's like a catalog of natural teeth, they can communicate with a patient on how big the variety of teeth are.
If a patient comes and says I want beautiful teeth, how should I know what's in his mind, so if you show him this broad selection then there's something you can start discussing on. When I had the book finished, that was I think almost fifteen years ago, I realized nobody knows me, nobody knows I'm actually a dentist who also likes to do this and I have my patients, and also I wanted to learn about ... I realized certain things myself on these models, but I wanted to know what was already being described on this.
So, I started researching all the literature, and started writing the book actually for me, and it somehow got out of hand. So I think I wrote that seven years, five or seven years, so my daughter, when she came, my wife came and said when our daughter gets born you stop with the book, because then we have two kids. I said yeah yeah, I will stop, and the moment my daughter was born I realized I didn't write anything on optimal properties and tooth color, so I have to do that as well, so that was another two years.
In the end it was quite a big book, and by that I learned everything I know about dental aesthetics, and the interesting thing is, I think it's quite ... it's not a imitative field, but it's not endless. You can learn anything about aesthetics and what teeth are like if you put effort into that. It's completely different than function, that you never stop learning, but aesthetics is something if you really want to learn about it, you can do that and be sure that, at a certain point, almost everything there is. So that was the story of the book.
Howard: I think that book ... I think you'd sell a lot of books turning that book into an online e-course on dental town, where you show pages and cases of those books, I think it would be a great online e-course and sell some books.
Jan: Actually, I already sent a webinar on some general principal, which contains content of the book, but I don't think what your idea, what you just said, would really work well, because the book actually contains old cases, I wrote that like ten years ago it was finished, so it came out in Germany 2005, and everybody who wants to know about the book can just read, buy the book and read the book.
Since then, a lot of things went into the book ...
Howard: Where can they buy the book, what website would they go on, what website would they go to?
Jan: There is a website, the online store of my publisher here. The publisher is team-brook media, and team-brook media, they have it listed in the U. S. but I think they didn't really push that a lot in the past. Now that the English book is out, actually there's only that website in Germany, but they ship everywhere, so ...
Howard: What's the website?
Jan: It's easiest, if people are interested in the things I do, if they look up my name, [inaudible 00:09:43], there I put all the links to my projects. There are the books, the models ...
Howard: And so that's www.hajto.de
Howard: And de stands for Deutschland
Howard: I want to ask you about that, are Americans the only one that call your country, Deutschland ... I mean when people come there from Sweden or Norway do they say, Oh I'm going to Germany or do they say I'm going to Deutschland?
Jan: I don't know how, in the Swedish language they say, they have a word for Germany, obviously, and the French they say [inaudible 00:10:21], so each language has it's word, as in Europe actually English is the common language, people from England or Italy, if they don't talk in their language, they say Germany. Deutschland only the Germans.
Howard: Really only Germans call it Deutschland?
Jan: Well I think so.
Howard: Huh, okay. So, what do you think, Jan, by the way it's pronounced Jan but in American it would be Jan. It's J-A-N.
Jan: You can say Jan, Jan is fine.
Howard: Oh no, we should try to say it the way your mom and dad ...
Jan: It's a female name in America right?
Howard: Well actually yeah, my dental assistant, Jan, she's been with me since day one, 28 years, and I'm going to start calling her Jan. What do you ... first of all, explain what do you mean when you say the biological foundation for the social role of teeth, or the genetic code of natural teeth? I think a weird word for me, is Americans seem to buy anything that's natural. There will be two brands, they'll say well this one's natural, and I'll say, well what is natural, I mean a tornado, a hurricane, a black hole sucking in a galaxy, so how do you define beauty.
I also have the perception that a lot of Europeans think Americans, their teeth are too white, like when they bleach them. I know when I go to England, a lot of dentists have told me, that a lot of cosmetic cases in America, they look like clowns. They bleach their teeth too white, they have veneers too big, so how do you really define beauty. You're into art, isn't beauty in the eye of the beholder? What is the biological foundation for the social role of teeth, or the genetic code of beautiful teeth that you talk about?
Jan: Actually, that's a lot of questions, you know. In the webinar, I just uploaded that yesterday, so I think nobody ... I think you technically might already have looked at it. There I explain about that in detail. So everybody that's interested in that should watch that webinar, because that's two times, seventy minutes, and actually it takes that long to explain all this in fact. Just maybe some short ideas or answers on this.
Beauty, and these things are also described more in detail in my book, because of course I couldn't come up with this all myself, I read a lot of literature, psychology, also literature on optical perception, on beauty, beautification of the body, aesthetic surgery and those things. Beauty is one of the most paradoxical things in the world.
It's similar to life, because life implies death. There is no life without death, and so beauty always contains some contradictions. You need some perfect idea to have something beautiful, but on the other hand in Germany there's a saying, a small mistakes make beautiful. If something is too perfect, too symmetrical, that doesn't look beautiful anymore.
Beauty is a kind of living order, it's not a mathematical order, like you put some numbers in a row, or building blocks, or really those ugly buildings ... so if we perceive something as beautiful, it must contain more, it must contain levels behind what is visible obviously. That can be a lot of things that you see in nature, coastlines or snow flakes, growing in nature. It always ... we perceive as humans, there is some rule behind it, or maybe even some divine purpose, but we cannot see it immediately that it's in a very simple order.
So, therefore, beauty is ... it is a curious thing, for thousands of years what is beauty. So, I cannot tell you what is beauty, especially in the case of teeth. We have to talk about a proclivity, and that is what I mean by the biological foundation, because we are biologically beings, we are primates, we live, and what we perceive on each other as beautiful, that has to do with attraction, sexual attraction.
How we believe that the other humans will behave to us, or how is genetic ... brings good genes, so it's worth reproducing. So, for that, teeth play an important role, and I found a very interesting book, a small book by a Canadian biologist, and put those things also in my book because I thought they are really true, and they helped me understand my patients better, that we are not just living and reproducing. We live in a rare construction. We have always some individuals who try to be the boss and ruler, and set the rules, and others who are more subordinate and follow.
It's not important to them to be ... to dominate. That is true for many animals and creatures, and in animals that live in such hierarchical structures of course there are also fights. We show off against each other, so weapons are of course important, and the most dangerous weapon of a primate are his teeth. You don't want to be bitten by a monkey. So, our teeth are our weapons.
Now, we don't use them anymore as weapons, except some years ago an American boxer I think, he used his teeth, so it might happen, but you know those sabers, which are parading on the military, they still have the word, saber, which they don't use anymore in modern combat, but they keep it in high respect because a weapon that we don't use anymore doesn't mean that we don't value it a lot. So weapon, and weapon bearing structures, those play an important role when we define each other in a hierarchy.
Those who want to dominate more, this helped me to understand my patients, especially for women, when you know all those ... you know the grey mouse, who doesn't' put on make up, who clothes are not so flashy, for those people it's better not to look perfect white teeth, they are more happy with some characteristics, some little bit change of the arrangement of the teeth, some crowding is fine for them.
On the other end of the scale you have those ladies who put their hair and spend hours in front of the mirror, and put their eye liner to the tenth of a millimeter, you better do perfect teeth on those, because they won't accept minimal deviations or even small stains, and they have eye of the eagle, and will tell you things you won't see yourself when you look.
So, that's what I mean by biological foundation, that teeth are part of our attractivity, and we have to understand that if we want to give the patient what the patient actually accepts, expects, or is later happy with. We cannot put the same teeth on everybody.
Howard: So, I want to ask you some specific questions. This woman, she's spent hours in front of the mirror, she's got all this ... her hairs all done up. She's got chemicals in it that stiffen it, moose whatever, hairspray. She puts make up, lipstick, all this stuff, so when she wants these perfect white teeth, do we really have to file down the tooth to make room for the thickness of the veneer, or can we just put laminate facing on the tooth, I mean that will thicken the tooth, but looking at the fact that she has fake boobs, she has lipstick on, she has chemicals in her hair, is adding one and a half millimeter of porcelain on the front of the tooth that big of a deal, or do we really need to reduce tooth structure ... so can you answer that?
Jan: That's a very good question, that's the first time I heard that. It's a very interesting question, and it shows me one thing, dentistry, it comes down to the question, what is dentistry.
Dentistry is medicine, it's a craft of course. Medicine ... Dentistry is also business, but I think mainly dentistry is philosophical science, because these things, we have to answer by thinking and trying to figure out theoretically, and that's a question like that, which I think really deserves a lot of consideration, because it really impacts the way we treat our patients, and what we will do on them.
I think, I never heard this question, and it has some points to it. I think it's a really legitimate to ask, if in the case we know that we go beyond the natural, because I call these patients that are so perfect they don't want natural, they want supernatural, or beyond natural, and I show once with my baby now how that looks, because these are synthetic teeth.
You won't find a single natural arch in a living person who is that perfect, so we have to perfect it, we have to really make it brighter, bigger, whatever. More like the media smile, which is more close. Actually you're right, I think it might be legitimate to deviate, to go away, from the natural dentition and edge on these teeth for the sake of not having to remove a healthy tooth substance and minimize the biological course.
I think there are things just to be considered, and I cannot answer you this question absolutely, I think there might, some other dental colleagues who listen to this and start thinking about it, and there comes some other points to their mind where they think, yeah, maybe this and this matter only.
A few things that come to my mind on this question are, if I know that my procedure is so long lasting, which actually today we reached with mother ceramics, with lycone silicates, and lythum desilicates, and our good bonding procedures, there is no literature that veneers can't among the long lasting procedures we have, and statistically they have the least failure rate.
There are studies with zero percent failure rate after ten years, so we don't have actually that with many other dental procedures. So when I'm ... when I know that there is such a good method, then why is it so bad to remove a little bit of tooth substance as I assume that it might last a lifetime. Actually when I do veneers I try to reach that, that's my goal.
I don't tell the patient I do this for five years or ten years, then we schedule the next appointment for redoing them, I hope they last for a lifetime. So I think that is not such a bring problem also to remove some tooth substance, if I gain other things for that. I don't do many non-type veneers, because it's not just that it looks bigger, but you close the proximal areas. Hygiene gets more difficult, you get margins that are not smooth anymore.
Veneer, you know best what veneer means literally, it's the piece of wood that it's put in the other piece of wood, so in the end it's really smooth and flat. So I prefer margins eliminate veneers that are really smooth, and don't add on to the true substance. So even if I don't prep I try to make a very slight margin so that I get them nice finishing line, which I can then polish, and it's really smooth, because that will last longer than other lines.
In additional ceramic on top of that, and there is one point, I don't want to talk too much about that, just mention it shortly, because I show a case like today in the webinar I send to you, where I had one or two favors where the person didn't tolerate this additional material. Especially when it collides with the lower lip, if the lower lip cannot glide smoothly above it. It's similar like with the lips that are blown up by some material.
People get functional or phonetic or comfort problems like that, so that's not worth saving substance on one hand and then the patient gets some other problems. So actually I always, we always when we plan veneer cases, we always do a slightly additional mix up. Everything that I can add on the additional arch I can also, I don't have to remove from the tooth substance, but I wouldn't say in general that it's a message to do it like that, because each arch is different.
You have arches which are very small, you can do non fit perfectly, but others, they are so flared out, so you have to remove a millimeter to be in the arch where you want to hold your latest result, and then still remove something to get there. So, actually I have a nice lecture on this issue of the veneer prep best from non prep to full invasive, and that would make a nice webinar, so if you like, my webinars, I'm really glad to put on topics like this one by one, in single segments.
Howard: I want to ask you ...
Jan: I answered your question all right, I didn't get off the point somewhere?
Howard: So cerac, the process of cerac, was actually started in France, but it really came to market from Germany, Serona, so my question to you is, when I got out of school the only way to really make a veneer was stacking feldspathic porcelain, and now you're in the home of Serona in Germany, cab-cam, can you make aesthetic veneers with cab-cam, or do you like the older traditional feldspathic? Or are there cases for both?
Jan: From the aesthetic, if I want to reach perfect aesthetics, you cannot beat the stacked porcelain, because there you can filter color differences already on very deep layers, you can put in all the individual effects in the tooth, and tooth structure is actually a very dynamic optical thing. It changes it's properties depending on the direction of light, and with all monolithic structures, you cannot reach that, it's really difficult to reach.
As we talked before, not every patient wants these characteristics, so if you have a patient who wants completely monochromatic teeth, which you have to talk about before with a patient, for example I made for me a picture with six different incisor characterizations so I can talk with a patient and ask him what he prefers so we don't do an incisor that is too translucent and then the patient is disappointed because we can't do anything like from completely opaque to very translucent.
So, it depends on the patient, and so from the aesthetic point, the nicest cases you see are always stacked and layered ceramics. From stability, from the point of stability, I prefer lithium desilicate, so actually I try to solve every case with lithium desilicate, plus some cut back and incisor characterization, because that material is simply three to four times more durable than the weak ceramics, and that is an advantage I don't want to give up. [inaudible 00:26:10] I did a few cases that actually, it's also possible to reach nice results, but you have to put so much effort into it, and surface texturing.
Actually Germany is a high wages country, so my hourly rate is much higher than a dental technician, if I can delegate something to the lab and he sits there for hours, and does the fine structures and everything, I would delegate that. In the lab he can also press it, he doesn't have to cut in minutes, so chair side, it's not really for me, I go to business option, to do it chair side, because you see perfect cases from like [inaudible 00:26:49] who uses the skin concept, but it takes hours.
For that, we have this division of labor here that, if it's something time consuming and the technician can do it, I in my office, I rather delegate that to the lab. You can't reach perfect results with all these methods of course.
Howard: So you're not really using, for your average veneer case, your just standard average veneer case, you're not really using cab-cam or feldspathic, you're mostly using lithium silicate?
Howard: What brand name is that, did you have any brand?
Jan: Lithium silicate, I think we can, usually avoid mentioning companies, and brand names, but the patents are still in place, so the IPS Emex, IPS Emex express, and IPS Emex cat from Iroclaire, those are lithium disilicates, and now there are some patents expired, so the company Vetox together with Dent Supply and [inaudible 00:27:59] a research institute in Germany, they developed a copy of that, it's silicone reinforced lithium silicate, pretty similar, but we have longest experience with the Emex, because they have so many different translucence and colors and also ingots that have a multi layer, so we have years of experience with that, but it was a learning curve.
If somebody starts work with that, go to those dental technicians that are really experienced, they can tell you all the tricks, because it's a tricky material. It has some properties that are not to our advantage, it turns a little bit greenish or translucent. You have to know how to handle it, if somebody really seriously thinks to work with that, then there are super experts like Oliver Blitz or Ubassy, who also co developed this material and is really versed to send you a dental technician there, to shorten your learning curve, because the really good results, you have to have some experience with it.
Howard: I was wondering also if Germany is very different than the United States in the fact that, if you did 100 veneer cases, what percent of those cases would be on females vs. males?
Jan: I would say about 70/30 percent.
Howard: Do you think that's changing, I mean, in my dad's generation, no man would get veneers, but in my generation maybe it's like, I would think maybe, I'm 52, I would think maybe ten percent might. I see the next generation in the United States, like you say, like 30/70, and I'm wondering do you think in 25 or 30 years cosmetics will be 50/50 men and women, or do you see it trending towards importance to both sexes, or do you think due to biological nature it will always be ...
Jan: The trend is there, it goes in that direction, but slowly, I don't know how long it will take when it's 50/50, or if it will be 50/50 at all, because, you know this is a question that goes in the field, will maybe males in thirty years use more make up, or put on some ...
In general I think we males are not so vane, for us it's not so important, I would put up your make up for this video conference, and I don't care if I have a head like you, if I lose my hair, but everybody is different. There are patients who come, and sometimes that's funny, when they come, and especially older males, and say I'm not really happy with my teeth, what can we do about it, sometimes they, when they are not so really confident, I'm not sure, my friends say you are crazy right I'm doing this, your teeth are healthy.
So I think, the social surroundings, where we live, our buddies, our beer drinking buddies whatever, that also influenced this. So if you maybe for yourself feel the need, oh I'm not so happy with that, but all your friends tell you, yeah you're crazy, you know, you want to make some veneers for yourself, that influences. I notice that with some patients who told me that actually their friends and their social circles won't understand that he comes here. So they almost sneak in the office.
Howard: Do you think the women, to put on make up and get cosmetic procedures, do you think that's a social pressure, or do you think that's a biological pressure? I mean like ...
Jan: I think that's out of my expertise.
Howard: Well you've done a lot of studying though, you've done a lot of reading on this, I think you might have read and studied more literature going back than anybody I know of.
Jan: There are different reasons why people do cosmetic procedures on themselves, and one of the important, or one of the most important reasons is the urge to belong to a certain category, or a certain group. That can be the need to belong to the normals, if you are deformed, if you have a burn, you don't want to be different. So you want to be like normal.
It depends on what is normal around you. Actually my partner, my office partner had an office in California. He practiced many years, he's originally from Europe, but he had a practice in Tulary, and he taught also at the UCLA, so he tells me a lot how Americans are, and he showed me some cases he did on people there in California, and as I understand it's especially California thing.
Maybe on the east coast it's different again, but in California where the sun shines, where everything is so bright, and people are beautiful and work out, and more people around you have all these super white bleached teeth, then you don't belong to them if you don't do something about it. So, your question was biology or social.
I think of course there's a biology foundation for that endorse play and goals, and they dress, and they love shoes and dressing and that. Not so many men like to go in the shoe store and test, spend hours to choose their shoes, so there is a difference, but I think it's also social because the surroundings you have, the country you live in, if you have different problems ... I think it also has to do with our wealthy society, because if you have different problems or you survive everyday and get your food and don't get stuck on some problems and some bar zones, and then you don't care about your teeth. If you have everything else in the world, what's left, yeah have nice teeth. So that also plays a role mind you.
Howard: So what pearls could you give dentist who want to do better aesthetic jobs, I'm going to give you ... do you have any tips on your standard veneer case on a woman, things that you think the 7,000 dentists listening to this might not think about enough, or tips you could give them.
Jan: I'm trying to think about some tips, sure, I have several tips. What I try to practice is a coherent philosophy, or coherent systematic dentistry, where everything fits together, because it starts actually with how you diagnose the patient, how much time you spend on understanding what the patient really wants, and the way you approach the planning and your analysis. So I try to go very structured, to do an aesthetic analysis.
I don't do long smile designs, because it can go fast if you have the expertise on that. The best tip I can give colleagues who want to be better aesthetic dentists is, you should really love what you do and spend a lot of time try to learn everything about it, be it in courses or you teach it yourself, but first of all, get yourself a digital camera and start photographing, because the photograph, digital photograph, is the third eye.
You cannot in any, in the webinar center I show you a few examples of how you cannot really measure, the eye deceives us very much, but photographs, they are objective, they can measure on, and you can document and also see what you did years ago and improve on that.
Another thing, I can give more like this general types, because I think that's what the underlying driver to get better. Never be content with the level you are at, because you can always be better, and there are always guys who are much better than you, and one doesn't have to go into extremes to remove every detail under the microscope, but there is always a level of perfection, and if you're ...
Interesting, if you look on Facebook, there are excellent cases, which are not published in high gloss magazines, but people just published them before and after, and you really see that you don't see anything, it's like, it's teeth that are so perfect the most aesthetically, so try always to improve and ask if what you do is really right, that is maybe one thing, and otherwise I think a structured approach.
Also that you as dentists get some competence on what you maybe believe is the competence field of the dental technician, because you cannot leave everything to the dental technician. If a patient is not happy they will come back to you, and ask you about it, so we have to be able to shape these problems, and we do that everyday on our composites.
So you have a chance to practice everyday on direct composites fillings, surface texture, layering things, and proportions. So then, better communicate with your dental technician, then get yourself a dental technician that really you form a team with, where you have a good communication, who understands what you can deliver, and you understand what the dental technician can deliver.
Because it's a team effort, the veneers, the ceramic itself will be done by the dental technician, and that is ... maybe it's interesting for you Americans, because that was, it is really different here in Germany. Here in Germany dental technicians have a much more important role. Sometimes they sit with a patient, they do trials, they work on the patient, because here in Germany we have to give the patient the invoice of the dental technician as it is.
I cannot buy prosthetic work like I buy materials, and I try to buy them cheap and sell them expensive and make my profit like that. No way. It's a law here that the dental technician writes an invoice and that invoice I give to my patient. So, by that automatically the dental technician has a different role because I think, and the reason the system is like that, you can optimize yourself buying the prosthetics.
I've heard stories that some people try to buy really cheap work from cheap labor countries, and because they have such a reputation they started expensive, that wouldn't work here at all. So that's also one reason. I think there's a lot more, but I don't know, if you think more of practical tips, I think it's a thing I can show in the webinar, how we work [inaudible 00:38:38] and then step by step achieve our result, because this step by step dentistry, I don't just prep teeth and give it to some dental technician, ask him to do nice teeth. We work with prototypes, we work with imaging, there's a lot of methods how you can pre-visualize your result, and one should know about these methods, but its' a huge field, and I think it's rather something I could explain with slides and examples.
Howard: It's interesting in the United States, all the, when you go to the hospital or you go to the doctor, you do get a direct bill from all the different people from the labs and all that kind of stuff like that. In dentistry in the United States it's different than that, then it is with U. S. hospitals, but in Germany the lab man sends the bill directly to the patient. I think that's a better system, do you, or do you like the United States dental system where you buy a crown from me and I pay the lab man.
Jan: It has both advantages and disadvantages, the advantage of our system is that certain ... some dentists do not take care to get ... become competent in certain fields, and there is a void which dental technicians then see, okay, if a dentist doesn't take care of that, I'm also not stupid, I will do that.
For example implant guides, or setting up full dentures. I think there are in Germany more dental technicians for good at setting up full dentures, but really also knowing about function and stuff, then dentists. So it erodes a little bit our competence as dentists.
On the other hand, if it's on a fair level and both are on the eye level, and I respect what the dental technician is good at certain things, and he respects my limits, it really works well. Of course, if you are clever dentistry is also business, so if you're a good business man and are able to find a good dental technician who works for cheap prices, I think I would have a more happy life than give all that big amount of money to the dental technician.
In Germany there are prosthetic cases that are half of the amount the patient pays goes to the dental technician, or even more, and as far as I know in the U. S. it's always only 25%, or a third at the maximum. So, because of that, our business side is a little bit more difficult, because we cannot really make some profit on that.
So, I don't know your system, I never lived it, but, I think both has it's upsides and downsides.
Howard: I want to ask you another question, if somebody does an Emax crown on a molar, and it chips, do you think that was from the Emax, or do you think that was from the inclusion? Is that even a fair question?
Jan: You ask questions where I could start talking two hours about it, because what you ask about implies information about material, and I could tell you a lot about the different ceramics and the properties and the materials, about function, which is a huge field, then also proper design, because ...
Okay, I try to give a few answers. Emax, actually doesn't chip, as far as I know the word chipping is a cohesive fracture, that means ceramic fractures within it's material. [inaudible 00:42:15] So the ceramic on top of the cerconia, that can chip within itself. Emax, if I see failures, those are mainly similar lunar or complete fractures, so that the Emax ... because usually it's a monolithic structure.
If you put layered ceramics on Emax it behaves very similar like the metal ceramic drones, so you have also chipping the metal ceramics, but really not so often like zarconia, so on Emax if you ask about the chipping, it might have been some prosthetics, and on top some big ceramics, then it might be that the ceramic is too weak.
Emax is actually in itself strong enough with the initial 500 mega pascal, 400-500 initial load, and also, it's here we have a very good dentist who also recommends it specifically for fractures, because it's still not too hard as zarconia, so it can adapt, and it's still a very strong material. It is very successful with that.
So, I know that, or I use Emax really as a reliable material, so if Emax breaks I think it's, it can be several over reasons, beginning from the way of sanitation or bonding, or the break, very often minimum thicknesses are not respected, especially on molars, because on molars you have a very very, very often not enough space. I may work in a larger digital lab here in Germany, and we do Emax clones for years now, for many many dentists, regular dentists, not specialists.
In a big percentage of the cases we have to call them and say, reduction wasn't enough, not enough staff or [inaudible 00:43:56], that's I think one of the most common reasons for that. Many other reasons, like for example, it's very important that when you adjust ceramics and in the mouth it's normal, perhaps, often to adjust them in the conclusion, you have to polish every ceramic, not only Emax, as good as you can. Really put some time and effort to give that a good surface, because those micro threads, you leave with a rough burn, those will later go inside the material and cause a cracks.
So, it goes through the whole clinical procedures, this possible reasons of chipping, and also mistakes in the lab of course. Varying temperatures, whatever, so I think ... there is not the single reason.
Howard: So, let's go to more specifics. How much material thickness do you need, how much thickness does the material need? A millimeter and a half, two millimeters, and what kind of shoulder do you want, you know some dentists are doing a bevel, some do a shoulder with a bevel, some just do a full shoulder, isn't a shoulder with a bevel at the end of the day just a bevel, what type of shoulder and thickness do you like on a molar?
Jan: On a molar, inclusion-ally I prefer 1.5 millimeters for crown, but you have to see the difference between a crown or an on lay and partial crown, so if it's really a full crown with a margin around infra-vascular and really submarginal or vagingeral, if it's a full covered crown, then the inclusion thickness is more important than for an on lay, because you have these side walls, and you have the inside of the stump, it's always can give you some forces, some inside forces, so there I go for the 1.5 millimeters.
Which, really cannot be reached every time. I prefer even lower, the minimum thickness officially on the clausal for on lays on 1mm, but not for crowns. So for crowns it's still 1.5 and for on lays or partial crowns it's 1 millimeter. There's interesting study done in Keve where they did even thinner ones in three groups, and the absolute minimum I use on on lays is 0.7. Below 0.7 you get problems, but in certain, or if certain areas you have a point and it's thinner then 1, that's okay, but on crowns 1.5, and the finish line I prefer a pronounced bevel.
So, not a 90 degree shoulder, but really a deep, a deeper bevel for that. Especially the press material, you can get very nice sharp margins on that, and it's ... I think what's more important than the design on the finish line is also the angle, your prep angle, because that very often is not steep enough. It also depends on the way of segmentation, because in go clear, officially, they allow you to cement Emax, and in my opinion that is a concession to the dentists who may be don't want to bond each crown, because it's really technically sensitive to bond on the last molar, the [inaudible 00:47:33] margins a crown really well.
So, I always do adhesives cementation on the image crowns. I always use a duel adhesive segment, I don't use [inaudible 00:47:43] or other cement than Emax because every cement profits from the strengthening on the inside by the cement.
Howard: What is your brand, will you go through your cementation process with your duel cure cementation process. What brand and how do you do it?
Jan: I love for the adhesive cementation duel pure-form for this post-ere things, and the interior for this I use light pure material, that's very late aesthetics, before it was very important, and now it's virulent aesthetic, actually I think that the brand name is not so important, once you use what works in your hands and you have the best results with, I'm sure there are also others. For the prosthetic duel pure, my hands what works very well, is from 3MS to the real, realize out with Scott Bond universal.
That is very few post operative sensitivities, highest bonding values you find, even better than the old Syntac and Opti-bond plastic systems. It has also, it's had aerobics, there is nothing perfect in dentistry, everything you use also has it's disadvantages, you just have to know that an inlet, and I live with that because I like the other advantages, the material has a very short gel point, so when you put on the light it cures very fast, which on the other side is good because it shows that it needs no energy from the light, and it cures also when you go through the crown, so you cannot really pre-cure it well because very soon it flips and is really hard.
The other thing is the material is rock solid. It's a composite, so when you have excess, you have really had sharp thin scalpers and sharp scalpel knife to remove it, but do that then and have a good bond. So if you want to live with these two properties of the material, it's radio packed, you have it in different problems, you have fine paste, and it comes auto-mixed with the mixing tip, and there really have clinically verifiable results with that.
Howard: Do you also use, for direct composites, do you also use a different direct composite for interiors verses posterior, what do you use on the interior teeth, and what direct composite do you use on the posterior teeth?
Jan: I'm no composite specialist and artist, I am prosthodontist, so I work mine indirectly. Of course I do my direct restorations as well, but I have an associate dentist who does all the direct composites, and if she uses, I forget the name but it's a dent-supply, probably the latest, a dent-supply composite on the capsules.
For years I'm really happy with the GC products, that is the genial, it was the genial before it was radium, now it's genial, the genial will have the flow, the no flow, and the capsules, the paste material, and actually differences on the posteriors on the last layer of the inclusion forces I use more the highly filled paste, but in the interiors I use the low flow material, it has a cord and is thick, it's a [inaudible 00:51:13] I don't know the exact name, but it's the genial of low flow I think, it has a very nice resistance.
I found for myself that composites that are too hard, they are more difficult to adapt to the margin, and the material that has a higher viscosity over, which is more liquid, it simply flows to the margins, and by that you get a good seal on the margins, so also in my posteriors I do the bottom of the box with some more flow-able, and then while the hard forces are on the tooth the more paste like composite.
Howard: You're a prosthodontist, you're focused on aesthetics, your ... you know a lot about the stomatognathic system, the TM, temporomandibular disorders, so I'm going to ask you a real world question, as a prosthodontist if you're doing a single, do you ever use a triple tray, a quadrant tray for like one unit, and when does that change to say no we need full arch impressions and mounted on an articulator.
Jan: Actually I am a big fan of the triple trays, and there's also a story behind that, because when we made our digital lab seven years ago we scanned ... we wanted to do a centralized, like a cat cam procedure. We wanted to scan the impressions, and in Germany use the metal trays, so actually I talked with Bill McKay from premier, and I think those are marketed and distributed, and we had our own triple trays made in our own color, and we did some studies on that.
In Germany it was not common at all, so I think that also had a little bit an influence that more dentists use a triple tray in Germany, because there was a lot of literature that showed that in certain cases it's even better than the two big impressions, where then in the end the models don't fit on each other and you really have to check the plaster so you're getting good inclusion.
So I use the triple trays a lot, and exactly as you said, single units, also two crowns, so I would say a row of in lays, even a quadrant of in lays, it was, you have [inaudible 00:53:32] restoration, and the tooth is stable enough. I think I wouldn't do it for a bridge anymore for three unit bridge, I also wouldn't do it if you have no posterior support on the last tooth, I use it always when I have tooth in between or maybe one second molar, one last tooth, so I always see that I have enough inclusor stability on the situation so I can recruit visibly the expectation closest mouth, and I think that's important with triple trays, you really have to put a lot of material in there.
The amount of material is what stabilizes the whole thing and you also have to check on the quadrilateral side before how the patient closes, and tell him how to bite that is really down, and sometimes I take an additional bi-registration to just be sure, if I'm not sure if you really bit down, especially when you look at the triple tray and the light shines through the other teeth, you know the inclusion is right, and for me that works for years perfectly. The fit isn't always so sure. I don't believe those who say you have to do everything with a big tray and full arch.
Sometimes some dental technicians told me, but I would have likes to have seen the quadrilateral tooth, so I know better the shape how it should be, so this is to be considered, or you give the dental technician a small impression of how the tooth looked before, but I think the triple tray absolutely belongs in every office, it's a good thing.
Howard: Since you see both sides of this, you're a prosthodontist and you see the lab side, where do you think optical impressions are today, do you think they're as quality as a polyethyle or a polyvinylsiloxane? Are you seeing, is Germany seeing more optical impressions coming into the lab, or are they still seeing more polyethyle polyvinyl, where do you think that's at right now?
Jan: I'm thinking how to answer you the most relevant things, because again I could talk two hours about this actually. Our company, we introduced, we offered to our dentists optical scanners, and also I love technology, so I was really excited about this, and I knew the Brontes guys before it became 3M, and we always wanted to have that scanner.
I'm really fascinated by these things, but today I see it differently. It's really still a long way to go, and one thing maybe, I told you already many dental companies and one thing that companies are working on are going away from the optical to go into ultrasound, so we really can go through soft tissue.
That will be a revolution. The moment we really can go through blood and soft tissue, and I think that will come. Ten years maybe, or fifteen, or it comes sooner, but that will be interesting. With the optical systems what most companies who offer that, in my opinion, they don't see right is that it's not an impression device.
They see it as a replacement for the impression, they see it as a prosthedontic device. I think optical scanners are very very important, will be in a few years the most important interface in any dental office, because it's a universal digitizing tool, and I compare it with the smart phone.
A smart phone is not a phone anymore, it's not a replacement for a phone, it can do so much more, but why can it do it? Because you have those apps. These scanner companies, they don't offer us the apps. I actually started a small development business with a free program because I had plenty ideas what everything you could do with inter-oral scans, and of course many of these companies know, but even the big companies in our market are small companies compared to some consumer companies, or mobile phone companies.
So they don't invest so much money into these things as we would need, so we could do longitudinal studies, we could check up on erosion, we could do so much with a digitizing tool, if it's not just regarded as replacement for the impression, because as a replacement for the impression, here in my office and I think in most offices in the U. S. as well, you have these mixing machines, they are standing in each room, it's just a push of the button and you have in half a minute filled up your tray and you're ready to go.
Today you have to shut down the [inaudible 00:58:05] in one room, carry it over, put in the plug, start up the computer, put in the patient name, do all this stuff, just to replace an impression. That's not a strength of these scanners, so I think they will come, but industry will have to do a lot more to offer us the advantages that it gets more useful to us.
Just replacing the impression is not enough use, so it's worth spending tens of thousands of dollars or Euros, and actually I think [inaudible 00:58:40] in a few years it belongs in each unit. In each unit next to your motor and your water spray you have the scanner and you just grab it and you scan, and you do some scans in between to check on your quality of your prep, so you can prep quality, and there are many of these ideas and apps that you can do, and I'm a little bit frustrated that these ideas we have six years, and yeah, but the companies they have their own schedules.
I read the dental industry, it doesn't move in fast steps, they move very slowly, they proceed, it's always their process, but nobody really runs ahead and tries something, because it will come by itself anyway. So I think it's a matter of time, today I wouldn't spend a lot of money on an infra scanner because I think they're also this business models that perhaps will actually profit from getting data. They will find ways to provide you with a cheap scanner and, the same like mobile phone companies, you get this for 40 dollars if you make the contract with them to use their network.
So that's not how ... I think there a quite good parallel to smart phones and the scanners, and they have to develop into this universal device, and away from a simple impression device.
Howard: Is any optical scanner now better than all the other ones? Is there a best one, or are they all pretty much the same?
Jan: No there are big differences, and I think if you look at all of the features of the scanners, then everything that is technically possible, and one scanner has, another scanner cannot allow itself anymore not to have. Example is coloring. If today you can do color and without powder, then it's a noble goal that other scanners still have powder and electrolytes, and saying they maybe have higher precision and quality because it's simply a feature nobody looks back and likes anymore.
I think, in the terms of precision there's enough literature that [inaudible 01:00:47] is really ahead, but that is powder and black and white, and in terms of ease of use and speed and comfort and also sufficient precision, the new trios, the one that was shown now on IDS, I will get it next week and I'm very curious to use it, because the model before already was quite good, and the Trios by three shape, that is also scanner, because three shape is a software company.
So I think from them I expect more the apps and the uses I can do with it, because that's their strength. 3M is not a software company, and actually somehow that scanner doesn't really fit into their range of products, because they stopped selling hardware, but still the scanner they sell, it's not a piece of hardware, the scanner is only one component of a full solution, and the one who offers the dental office a scanner must offer the full solution in many areas.
That's why [inaudible 01:01:48] is so successful, because the scanner is not a scanner, it was the means to be able to be able to do chair side, so it wasn't ... a component of one whole system, and the people bought the system and not the scanner. So I think the trios is a scanner really worth looking at, and in regards of scanner first we have to decide how your office concept is, what do you want to do with the scanner.
Do you want to use it for prosthetics, or [inaudible 01:02:19], orthodontists, orthodontists use scanners actually quite successfully because they delegate, that's also good thing, and in Germany dentist is the one who takes impression, so if you can delegate your impression, you have a really good assistant whose good at taking literal impressions, perhaps incorporating your scanner, but you have to think about your whole office philosophy and how you want to incorporate this digital piece of hardware, and it's not about the device actually, that's how I see it.
Howard: I'm going to ask you one final question, cause we are over the hour, we are at an hour and two minutes, thank you so much. One overtime question, you don't see to be biased at all about what country makes what product, you're talking about countries all over the world. A country near you, Finland plan Mecca, just bought E4D, which was the second largest cad cam in the United States, do you think that will be a game changer or do you think Serona is so far out ahead in Cad Cam that plan Mecca is not going to catch up?
Jan: It will not be a game changer because, it's not only Plan Mecca, there's also Care Stream, and there is also Nura. Nura is a very interesting company, it's a french system, and they sell in France, and I think even also in the U. S. They have an interesting business model, and also I am ... I have the [inaudible 01:03:40] in my house.
I have also E4D in my office, because my partner, he used E4D and he loved it, and we got one E4D from 3M here in [inaudible 01:03:50] very close to us, and I got the E4D at that time when they did the integration of the [inaudible 01:03:55] with the E4D, and then there it was circed by Mecca, but I think nothing will be a game changer.
Actually what Plan Mecca or E4D do, it's a clone of Ceric. You don't see much difference, the software is nicer, much better, I really think it's more intuitive, but in the end Care Stream, Plan Mecca, Serona, they offer quite a similar thing, and I think those dentists for whom this is interesting, they already went this way.
So a game changer can be a system that costs like only a fraction of what Serona costs now, if you can get the whole thing for a few thousand dollars or Euros then you get more dentists who use it, or if you offer a different business model. Like a flat fee or something, where you provide also materials.
I think one big side effect is their service, all these things will only work if you provide a solution to the office and you give perfect service. For example, I, [inaudible 01:04:54] I do chair side, but I don't enjoy it, because I have to perform in front of the patient. So, this new company, they team up with three shape lens, and the three shape lens I can book time slots, I can schedule my patients, which I know how to do my prep, and then I send the patient home for a few hours, or he goes to the city, and I schedule the time slot with the lab, where three shape experts sit and do all my design.
For me it's expensive with my own way to sit there and play around with the computer, and also I don't have a dental assistant who does that. I think it's about the model how you incorporate it, and the level of support and service you get from this company, and the better they support for you, and reach up for you for every question, then they can be successful.
I don't see in Germany Plan Mecca or Care Stream catch on, and I don't know how many users they have, but for sure it's not exploding this market, I can tell you that.
Howard: Well I'm telling you Jan, thank you so much for doing this for me, I really really wanted to interview you for a long time, and the fact that you stayed up until 10 O'clock in Munich to do this for me, thank you so much for all that you've done for dentistry, thank you for sending us your webinar that we'll be putting up on dental town, and I just ... thank you so much for all that you do.
Jan: Thank you for inviting me, and actually I would be really glad to put up some more of the webinars, I think we talked about several topics now, which show ... actually these are the areas I'm also teaching, and I can show cases and materials, so I am in touch with Howard Goldstein, and I think if you have something you want to know more about, let me know, and we'll do the webinars.
Howard: And they can reach you at WWW.HAJTO.DE
Jan: That's my website, I'm thinking if there is an email, actually my email address is my name H-A-J-T-O, at smile minus art DE. Smile minus art dot DE is our office website, where actually, that's maybe important, many of my publications I put up there as PDFs, so if you want to see what I publish, cases and case reports and stuff, and also scientific things I did with professor [inaudible 01:07:18], you will find a lot of stuff there as well.
Howard: And every ...
Jan: Also let ... I'm sorry question?
Howard: And I hope everybody listening commits at one time in their life, they have to go to the Calogne meeting in Germany, and the reason I asked about Deutschland is I almost missed my flight, I flew from Phoenix to New York to London, and I was looking for Calogne Germany, and I spelled Calogne C-A-L-O-G-N-E Germany, and I couldn't find my connecting flight, and I was panicking, finally I saw a pilot and I was like how come they don't have the flight listed to Calogne Germany, and he said because it's, you're an American, it's Koin Deutschland, and he showed me the K, and I saw Koin Deutschland and I said okay.
Jan: Next time you are at IDS we should meet in person.
Howard: I will look you up. Thank you so much. Bye bye.
Jan: Bye everybody.