Blog Author: Thomas Monahan
Just wanted to share a 3 year recall on one of our earlier anterior cases. Patient finally allowed me to replace an old existing PFM. What was interesting about this case is the spacing was not the same and we informed the patient of the challenge. She did not want to pursue ortho, so we had to mask the discrepancy with contouring. Overall, I think it turned out well and the material has held up great over the last 3 years. Again, if you are not doing anteriors, get yourself to Level 4 in Scottsdale or Charlotte to get some training.
This was Vita Triluxe done with 1 fire.
3 year Recall:
Patient presented wanting his smile fixed. Concerned with the laterals and #5. After 5 years of seeing him finally allowed me to do 7 first. Once he saw it signed up to do 5 and 10 in 2 weeks. When we finished this week he said now he can stop smiling on just one side. 😂 Vita Triluxe 7,10. Empress CAD 5. It is very rewarding to be able to change a patient’s esteem with their smile.
Hope everyone has a great weekend.
To get to the second one...
Patient is going through an extensive treatment plan but was concerned about #7. He stated he feels like he has a hole there when he smiled, and because it sat so far back, it was dark. He is not interested in ortho but asked if we could “bring it forward.” He wasn't interested in #10 before this, before anyone asks. We were able to help him out today and now he is ready to do #10 interestingly. Very minimal prep on facial and I’ll try and dig up prep photo tomorrow.
Felt like value is slightly low. Assistant did a great job with block selection and stain and glaze. One critique may have been we could have used a lighter cement. Great to take photos after these to learn and critique your work.
Block is Vita Triluxe 3m2
Try In out of miller
So I have been working on this case for just over a month and delivered it today. Patient had CC of misaligned teeth and failing composites. Declined ortho, don't blame her she is 71. However, she was made aware of how much I was planning to "pull back" her teeth based on our waxup and how everything overalyed with CEREC. So again, here is how I used our technology and software to our advantage.
I scanned the patient with the 4.5.2 software and exported the STL files. They were sent along with photos via dropbox to my lab with instructions on the case.
We received the mockup back as an STL file and printed using Form Lab 2 printer.
I opened her case back up and then scanned the digital waxup and overalyed to show the patient at her consult. After she agreed with proceeded with the case.
We rough prepped the teeth and delivered the mockup to the mouth, using it as a reduction guide for the case.
When I tried to deliver the bisacryl temps, I nor the patient liked the midline, it was slightly off. So I used the digital model and editted the design and milled out Lava Ultimate temps. This is how tissue presented after 2 weeks.
After approval of the provisionals, we printed her prepped arch and milled 4 vita mark 2 crowns. Here is the following lab process:
These were delivered today. So we will get the patient back in a week or two for finals. But really thrilled with the outcome. I didn't see the "junk" until after the photos .
These types of cases have become very predictable in my office. From sending it digitally to the lab and visually seeing how much we are removing, to having a model ready for fine tuning the restorations, I think 3D printing is taking a big part of our digital dentistry arsenal.
Happy Friday all,
And GO Dawgs!!!!
Wanted to post this case we did right before the holidays. Patient presented to the office with a failing filling we had done about 2 years ago. At that time I had informed her that it would be a temporary fix due to size of the restoration and how much tooth structure destruction the decay had caused. When she presented the composite had debonded and informed her it was time for full coverage. She has several other issues going on, but she is a "come in when something hurts or breaks patient." I find that with CEREC we can treat these patients on the same day and give them what they want (single visit emergency treatment) since she is not seeking comprehensive treatment.
Since the facial surface of the tooth is in decent shape, meaning I can copy the line angles, it gives me a great starting point for contouring. Biocopy in 4.5.2 has be great so I have been using it more and more in these scenarios. There is a lot less design time for me in these instances.
Preop Condition showing failing composites on mesial and distal:
Shade selection: when I'm looking at teeth I try and look at surrounding teeth and contralateral tooth. I see 3 clear zones in the teeth with a significant area of translucency at the incisal. Vita Triluxe and eMax would be on the list for my choices. You could use empress multi, but I think all of us have favorite materials for anteriors. Vita Triluxe 2M1 selected.
Preparation was very conservative trying to follow 3 plane reduction. Also, if find sometimes dentists will not prep subgingival at the interproximal areas. If you want to get good emergence in my opinion you have to do this. Now there are a lot of factors: bone level, tissue health, spacing, etc... But keeping the prep above the tissue in these areas will not create a great emergence.
Immediate Delivery. Don't worry tissue will fill it. As Mike says, biology will win. My assistant did all the characterization. I still like to do the contouring, prepolishing, and post polishing. I thought she went a little too much with the white but it turned out great I think.
Final Pics After 8 days showing great tissue response:
Overall good outcome. I know I missed that mesial line angle. Saw it after I was loading the photos. Best advice that was given to me was to take photos of cases if you want to improve. You will see so much that you don't catch in that moment.
Everyone Stay Warm.....
Oh, and did I say GOOOOOOOO Dawgs!!!!!! My heart finally recovered after Monday, ready to go now....
I wanted to share my experience from some of these larger cases I have completed recently. First off, Level 4 was a huge help and I cannot give that course enough credit. Sam, Mike, and Mark do a great job updating the content and making sure to cover as much as possible. Everytime I mentor a Level 4 course I pick up something new that I can use when I get back to the office.
I took photos throughout the process, but don't want to overload with too many on this thread. What I did want to point out was how the process of Cerec and milling gets you about 80 % there. The mill likes to mill rounded angles so even with copying the waxup/mockup you will still have some work to do post milling. The models were ordered by exporting the case after margination as a .dxd file. Upload to Infinident and they will send nice solid models as well as trimmed models in about 3-4 days. Cost about $25. They can also send an opposing. Most of these cases I'll rely on the biocopy and never order the opposing.
Tips to make this process flow:
1. Get a good waxup from your lab. Most of the time they will waxup in grey or blue to allow contours to pop. A siltec stint or any putty stint should be made as well.
2. Transfer that to the mouth. I dont like trying to stitch the preps in the mouth to a waxup off a model. Have the patient work out the occlusion and copy that for your biocopy.
3. Any teeth more than 2, I do in 2 visits. Its just too stressful for me. Order a model and work on your own time.
4. Contour and prepolish then crystalize. (obviously if using Emax)
5. Then add characteristics with stains and fire. Finally glaze. If I separate these steps it just helps visualize the outcomes.
Preop Situation. Patient wanted spaces closed and new partials made to allow her to eat. Ortho was declined even though at a young 78 she probably could have done it. Emax A2 MT
Test Drive. She wore these for about 3 weeks. Had to adjust occlusion once.
Initial Milled Models crowns on models from Infinident
Contouring and Prepolish. Used all burs from Cerec Doctors Kit
Stain and Glaze:
Several old restorations needed attention. Patient's OH is unfortunately not as good, but he is improving. His dexterity is not great due to medical condition. Electric tooth brush hopefully will help him. Posterior teeth were not built out to fill buccal corridor because he did not want to redo his LPD. So had to compromise. Also, had to compromise with him on shade. I did not want to go that white. Emax MT A1
Hopefully this shows how important these post milling steps are. Do yourself a favor and if you really want to start doing some anteriors, check in to Level 4, totally worth your time.
It's just amazing what we get to do everyday and the technology we can do it with. The excitement level from patients to my team just keeps getting better and better. I wanted to post these 2 cases because the "dreaded single central" are the most challenging cases to me. And somehow we have had 2 this week.
People always ask, "what material I should use for this case....". And as all of us know it varies. So just wanted to show 2 different materials that you can use on a day to day basis. I will have to say that I could not do this type of anterior without a very passionate team member. My assistant is very talented with staining a glazing and is an invaluable asset to my cosmetic work.
Case 1: 61 year old male that had a 30 year old PFM that I have been asking at every hygiene check if he wanted to replace. Every year, no not this year, not bothering me. Well this year was the year. He decided to replace it. Used biojaw to get good starting point and then refined post mill. Was very happy just from the initial try in with no stain or glaze. This case was Vita Triluxe, 1 fire.
Case 2: 66 year old female with #8 having RCT a while ago and had 2 large composite fillings on the lingual. Decision was made for full coverage since they were leaking and a redo filling was not a great option. Discussed doing some ortho or involving more teeth, but patient decided on just 1. So had lengthy discussion of copying existing size and shape. Biocopy was used on this case. Vita Mark 2 with 2 fires (1 stain and 1 glaze). Value may be a little low, but will see in a few weeks after teeth rehydrate.
After seeing all of Kris' cases and hanging out with her mentoring lvl 2,4 and accept two weeks ago, figured I'd do my best to try and post a good before and after.
Patient has had a hx of throat cancer and treatment did a load on his dentition. So trying to start somewhere. He wanted to fix his front teeth if we could first. With malposition of existing lowers, decay had taken its toll. 23,24 fillings and 25-27 crowns. Had to more aggressively prep #27 to "turn" it into the arch form. Think we ended up with a pretty good result. Biojaw was extremely useful here, which is why in my opinion 4.4 is so good. Great case to finish the week!!
Props to my assistant for staining and glazing.
Just finished this case before lunch. And I wanted to thank Bill Marais and Mike Skramstad for bringing this to the table. The enamel mixture Bill describes in the webinar just gives another level to what we can do with cosmetics on these restorations. I thought I would share, and have to give all credit to my assistant on this one. She is getting scary good. Everyone enjoy the weekend....
Of course, no preop image (restoring due to ill fitting large composite), but took prep, tryin and after...
I thought'd I'd post this case for some critique. Still trying to learn characterization skills. Mike's videos have really helped me and I'm assuming several others with contouring these restorations. Here's how I approached this case.
Patient presented with cosmetic concerns with 8 and 9. Crowns were connected with who knows what underneath. Both previous root canal treated.
Had a mockup done and scheduled patient to have crowns removed. This is what we were left with.
After prepping, placing new post in #9, BU and making temps, this is what she left with. Had plenty of ferrule even though it doesn't appear that way. And of course I dont carry every temp shade, but will now order some staining material for them. She was nice enough that she did not care.
Patient returned in a few weeks so I could scan the biocopy. I had taken one the day of the work, but saved the .rstimg file just in case she wanted some changes. When she came back I took a new image just because I had the idea of putting a marker for the midline for reference. Sometimes I feel like the proposals start looking weird so I decided to see if this worked. And it did help.
Biocopy with refernece line from sharpie. It did help, i moved the midline a bit to line it up.
Tissue healed before cementation after removal of temps:
Then here are the finals immediate post op. She was thrilled. I think we could have done more translucency and the incisal embrasure is bugging me. Other than that, successful case. Just wanted to share the sharpie thing, in case that could help people in the future.
Cant wait for Cerec 30.