Blog Author: Kristine Aadland
This is just one of those cases that meant a lot to me. This women walked in my practice looking for a third or fourth consult for her front teeth. She was celebrating 1 year of being cancer free after undergoing pretty severe chemo and radiation with low survival rates. She beat the odds but her teeth suffered. She had something to smile about now and wanted her teeth to reflect that. She hated her smile and I was so grateful that she chose me because I wanted to be a part of her story.
Major damage from erosion was done to teeth #7-10. The canines also show buccal erosion and pitting on the cusp tips. She has obvious tetracycline staining as well and in her smile we decided to work from #5-12 knowing that she could always add in #4 and #13 at a later date if she wanted.
When I am looking at the shape of her teeth, I see that the laterals are a bit wide, I want to lengthen #8 and 9 due to the amount of wear and erosion (meaning I have to pay attention to occlusion here) but I really like the overall shape of her teeth.
I set this up in the computer as Biogeneric Individual, but then manually add a BioCopy Upper folder so that I know where her midline, incisal length papillae are.
This is a case I delivered in one appointment and a tip that I have definitely learned over the years is to trust biology. I have a huge fear of black triangles and I know I am not alone. Patients hate the look of having pepper stuck in their teeth and are always asking if we can fix it. It's not an easy task with a tiny bit of composite for natural teeth, and then with crowns, I just used to make these long, broad contacts to avoid it at all costs. The problem with those long, broad contacts is that they just don't look quite right. Now it's this constant struggle in my mind of making sure there is no black triangle and trusting biology to fill in the triangle.
Here is an example of that-
1 week post op and praying to the papillae gods
3 week post op
This was such a fun case for my entire team getting to know this woman who has more courage and strength than I could fathom. She affected every one of my team members in a positive manner and now can't stop smiling. She scheduled to do her lower anteriors in a month and I can't wait. She was an amazing reminder of why I love what I do.
Over the last few years as I have become more involved in the CEREC community, I have had the pleasure of being surrounded by some incredibly talented dentists. Often these dentists will show me their cases and I am constantly in awe of what they have accomplished in such a short amount of time using their CEREC. What I love even more is their drive on how to improve their skills even more. My constant push (and often harassment) is to get these doctors to post their cases but posting can be intimidating. I hear over and over the same reasons why doctors won't post cases: "my work isn't good enough", "I don't have anything new to share", "people can be mean in their feedback and I don't want to be bullied", etc... As a CEREC doctor we take a lot of pride in our cases because often we create them with our own hands, so getting feedback feels personal. My point in this post is to show a progression of what you can do if you are vulnerable enough to put yourself out there and try.
Here are some of my early cases starting in 2010. I happen to have a really poor post-op photo of my very first anterior case. I was so proud of this when I first began using my CEREC.
One of the best pearls I got in a class was if you want to improve, start taking pictures of your cases, so I did. The problem was my photography wasn't stellar and I still didn't know what I was looking for to be able to make improvements. These restorations definitely made improvements in each of these patient's smiles, but now when I see these cases...
Jumping ahead a few years, I got involved with the mentor group and started posting cases more often. This case in particular was one that was emotional to my entire team because we watched the physical changes that took place with this patient after we changed her smile. I was so proud of this case. After I posted, Mike Skramstad took the time to photoshop the case on ways I could improve it. My first reaction was nausea and to quite dentistry, but once I could reframe that and understand that he was truly trying to help me improve, it was so much easier to actually see what he was talking about with the photoshopped photos so that the next time I wouldn't make the same mistakes. Now did I cut the crowns off and redo the case? Absolutely not. This patient was thrilled. She could not see the nuances that we can, but what I learned from the feedback was unvaluable to my growth as a dentist. It also became a challenge over the next years to see what cases did or did not need photoshopped .
After case after case after case, I began to actually see the nuances of line angles and color patterns and became much more comfortable with my anterior work as the cases became more repeatable.
Now if a case like this walks in the door, it's not a huge deal to squeeze them in and get a good result for our patients. All of this is because of the constant feedback from this community. It's fun to see how all of us have improved over the last 9 years as technology has changed, materials have changed and how we constantly challenge each other. I wouldn't change my path for anything in the world, but I do hope that it takes others a lot less time than it took me to make restorations look natural ;)
My team was asking me when I choose multilayer vs screw retained crowns not long ago. I personally try to do screw retained implant crowns whenever possible, but if I get an implant back that is a little too angled it doesn't make it possible without opening the contact up. I put some slides together for a visual and just thought I would share in case anyone else wants to use them.
*If you are not using your CEREC to restore implants, get down to the level 3 course and learn how! It is your biggest ROI with your investment and once you do it a few times, you quickly see how straight forward it really is.
Happy Monday everyone!!!
Today was a really great day. I got the opportunity to test out the new e.max ZirCAD MT Multi Block. I had one bridge block and one single unit block so I was patiently waiting for a patient with the proper shade.
This patient presented with a bridge needed from #27-29 and a crown on #30.
Here is the bridge right after being sintered
and at try-in
I decided I wanted to add a little characterization so I added Empress Stain and Glaze
Normally this was not something I would do same day but I scheduled this appointment on a Friday that I wasn't normally working so that I could document everything. She was well aware that there would be some down time. What I didn't quite realize was that the sintering time would 144 min. What to do with 144 extra min?? Why not address the front teeth?
She had a lot of large fillings in the anterior with recurrent decay and she wanted a better smile to boost her confidence. In the 2.5 hrs that we waited for the bridge, we made these using e.max A2 MT blocks
And did this...
I asked her at the seat of the anteriors if she wanted to see them before I bonded them in. She said that she trusted me and wanted a surprise.
Purchase a Premium Membershipto watch the full version of this video plus hundreds more. Subscribe Today
Today was a great day and the reason I truly love what I do
A friend of mine was referred this case by her surgeon. I was really hoping the bite was off but it was verified. My suggestion was to bury the implant on #2 and just restore #3. This stuff makes me so sad and now she has to tell the patient that one of the implants was a waste of money... Rough day for both patient and restoring doctor.
This was my first 6 unit case with PrimeScan. From the time the patient was seated until he walked out the door, this case took 4 hours with one mill. Between the faster imaging, the 5 click process and faster proposals, this is a noticeable difference in time for me.
This patient is in sales and has always wanted a better smile. We did the upper 6 last year and he like them so much he wanted to do the lower as well. This case is a perfect case to open his VDO but he has implants in all 4 quads and wasn't ready for that kind of financial commitment so we discussed what was realistic as far as how big the teeth would look and went for it.
A couple of things I wanted to share with this case...
One of my favorite things I do when I work with anteriors is to design in BioIndividual but add a BioCopy folder for reference.
This comes in handy to know where your midline is and how much you want to increase your incisal length if you have the room. The software program does not use this folder for proposals and you don't have to draw the copy line (which speeds up the case). It is purely for reference if you select the BioIndividual in Administration.
To turn on the BioCopy you click on Display Objects and then click on Lower BioCopy. Depending on which folder has the larger teeth you then use the slider bar to make the larger teeth more transparent so you can see the difference between the proposals and the original teeth. If the proposals are the larger teeth, make sure you group the teeth together so that they will all turn transparent or you will only be able to see one at a time.
My second recent find is an Ivoclar product called Cervitec Plus. It is a Chlorhexidine varnish that does not stain or taste. You dry the teeth and tissue and place it with a microbrush. It helps with sensitivity and tissue healing and I have absolutely fallen in love with this product. Here is a picture at seat date and one less than a week later. This patient has gingival hyperplasia from meds and his tissue is always a mess. I was so shocked at how fast he healed. My hygiene team has been using it a lot for perio as well and have loved the results at recall.
Here is a patient that recently came to me frustrated because she had three different dentists try to fix her front tooth and the shade was "never quite right." She had pretty severe trauma that resulted in a root canal and it needed full coverage due to missing tooth structure.
Anytime I hear that a patient has gone to multiple dentists I get a little nervous. She was upset because the first dentist "cut down her tooth a lot" and "it turned black underneath." She lost trust in the first dentist and went to the next dentist where other problems kept happening. One of the other dentists referred her to me to see what I could do.
She liked the shape of the tooth, but the crown was definitely bright. Part of the problem I saw was that her teeth were pretty translucent and the previous dentists kept trying to use zirconia to mask the darkness of the prepped tooth. This is when opaquers come in so handy!
I applied the pink opaquer to mask the black and then used buildup material and A1 opaquer to make the substructure appear more natural.
I milled out both an e.max B1 MT block and a Vita Mark II, 1M1 block for this case and I ended up using the Vita block. I wasn't worried about strength as much as I was about the color. The Vita tended to have a little more warmth in it than the e.max.
I warned her ahead of time that I couldn't get rid of the greyness of her root showing slightly at the gums, but with her smile I think it masked pretty well. The opaquers were my saving grace for sure in this case.
Here is one more reason why I love CEREC!
This is a young woman who isn't quite finished with ortho but has senior pictures coming up and pictures trump finished occlusion so I discussed it with the orthodontist and she didn't see a reason why we couldn't restore the laterals.
What I love about this case is that it is about as conservative as you can possibly get. My assistant pumiced the tooth, imaged and then started the design process. I finished the design, we milled it with GC Cerasmart, polished and bonded them on. I did nothing fancy with this case- no characterizing, just contouring and polishing. It was efficient and effective.
Implant crowns are by far my biggest ROI when using my CEREC and I love not only how simple the process can be but how gorgeous they are. I schedule my patients for two, 30 min appointments and often they are out the door before that. My assistants do the initial scanning, the initial design, and then I check it and make sure I like the emergence profile and push mill (this way I can say I made it ;). My assistant places the crown on the Tibase and we get the patient in within a few days at the most. My personal time with the patient is typically about 10 min unless there is a hiccup. It's amazing.
We have really been trying to focus on just taking a few minutes to contour and characterize all of our restorations instead of racing from the mill to the oven. It's so much fun for my team to see what they are capable of doing and it really does just take a few extra minutes.
If you are not doing implant restorations, do yourself and your patients a favor and take level 3! You will love the results!!
I was organizing some case photos and ran across these pics.
The first set of veneers were done back in 2007 with the Redcam using Vita Mark II blocks. The new veneers were done in 2016 with the Omnicam using Vita Triluxe blocks and I added staining at the incisal edge to give it the halo effect. I love to to characterize but sometimes there is beauty in the simplicity.
I did not redo these veneers because they were failing. I redid them because my skills improved and I knew I could do better. This is my charside assistant who I stare at every day and I was so happy she let me redo them. She shows them off to patients all of the time when they are nervous about getting restorations done in the anterior. She is one of my best marketers!
Going on 13 years of being a CEREC user and I still learn tips daily on how to make my restorations better and increase my skills as a practitioner. I love what we get to do every day!