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Here is a woman that came in with an old PFM that had recurrent decay but she was nervous to replace it because she didn't want the new one to "stick out". These are the cases I love!!
One tip that I like to do is mix my stains to get the color I want to achieve. This is a great example of that. She is pretty bright overall with a lot of translucency. Normally when I use brighter shades like B1 I would use "I 1" (the blue stain) to mimic the translucency, but in her case blue was just too bright- so I mixed it with the "I 2" (the grey stain) to tone it down but still give it some richness in color. I did the same thing for the body stain as well. The "1" stain (A range) was just a little too strong, so I mixed it with "creme" to tone it down. This only takes a few extra seconds but it gives you a huge palate of colors if you are willing to mix them.
The second tip that I have learned from others on this site is to look at the case from different exposures. I just wanted to show that in this example with the two different pictures- immediate seat and follow up. Looking at the different exposures can really help see the color in the tooth in more distinction. To do this with my twin flash, I take one picture with my flashes all the way tilted back and take a second photo with my flashes all the way tilted forward. Some of this will depend on the light in the room as well, but this is just a fast way for me to look at the teeth in different light. You can also do this on a lot of apps- like the photo app on your iphone.
What do I do when I am done with these cases? I look at my photos and see what I would have done to change it. I do this with my assistant, never in front of a patient. This is how we all learn to be better and hopefully improve with each case. Posting cases are also a great way for all of us to improve. That is the value of cerecdoctors!
Here is what I would have done differently:
I would have added either a little bit of glaze to the mesial incisal corner to sharpen it, or contoured #8 to match. This is an area that drives me nuts. If you use the smooth tool at all in the area it will round the mesial incisal edge and this is what you will get. I try to over close this area prior to mill just for this reason, but I got a little carried away here in my contouring.
I would have used "creme" for the craze lines instead of white. In the mouth this doesn't show up as dramatic but my camera never lies. Using creme would have been more subtle and matched her other teeth better.
One tip that I picked up from some cases here on the boards- add the body stain at the incisal edge of worn looking teeth. Often if you look at anterior teeth there is a lot of color right at the incisal edge- dentin showing through with the wear. I love to add a little of the same color I used at the gingival 1/3 here to mimick the other teeth.
What was cool about this case- The patient was in my chair for 2 hours and left with a new crown that she loved. That is the power of CEREC that we have available to us every day.
Anterior Celtra Duo Case shade LT C2, bonded with Calibra Ceram Resin Cement, milled in EF mode, designed in biogeneric individual but I always grab a pre-op "biocopy" catalog for reference during design. I only imaged two catalogs in this case as I again utilize the biocopy overlay to asses my occlusion during design phase - areas I could have improved on would have been to make the teeth more square like original teeth but she was very happy with the outcome - enjoy your weekend everyone.
One of my favorite CEREC uses is making a Maryland bridge as a temporary on the day of implant surgery. I like to use a hybrid composite material for this because it mills quickly, polishes well and is easy to bond in and cut out after healing, but it's not a material option in administration if a bridge is selected. My Ivoclar rep gave me some Tetric Cad to try and one of the nice things about this material is that it's dimensionally the same as an emax 14 block. You can set up a bridge in administration, select emax, but place a Tetric Cad block in and it will mill perfectly. It mills super fast and looks nice as a temp.
22 year old with congenitally missing lateral. I needed to place a 3.0 Xive implant, so Atlantis will make the abutment.
I've had the opportunity to use the new Tetric Cad material from Ivoclar for a few weeks now. This material is a great addition to the current available resilient/hybrid materials that we already have.
I really despise doing quadrants of composites. There's nothing I dislike more than trying to get good contours, interproximal embrasures and contacts with sectional matrices, rings, and wedges.
I would rather let the CEREC do the work for me.
This case walked in a few days ago.
Pt needed partial coverage restoration on #14 and also a restoration on #13.
Sure, I could have prepped a crown on #14. But I prefer to save tooth structure and not do full coverage unless absolutely necessary. Rather than filling #13 directly, with the CEREC Im able to create better emergences, and more predictable contacts.
The Tetric CAD material mills very quick and clean due to the resin component of the block. Using two Milling Units, both restorations were done in under 8 min.
After milling, my assistant removes the sprues, defines the anatomy and polishes the restorations with the Lava Ultimate Polishing kit from Diashine.
Per the IFUs, the intaglio of the restorations were sandblasted and then Adhese Universal was applied, air thinned and not cured.
Enamel was selectively etched with phosphoric acid, Adhese universal applied, air thinned and cured. Variolink Esthetic DC was placed into both preps, and the restorations were seated. This cement is great with a long tack cure making multiple units easy to clean up.
We selected Variolink Esthetic DC Warm with the MT A3 Tetric CAD and ended up with a nice final shade. The warm cement along with the MT block also helps to block out some of the underlying discolored tooth structure.
Forgive the immediate post op pic.
Entire appointment from anesthesia to post op BW was under one hour.
Pt was thrilled
Here is just a routine crown on #14. What I love is that adding a tiny bit of customization literally took less than 2 min and it can make such a difference...
e.max crown, A2 HT. I chose HT because she already has natural grey showing through and I don't stock C shades. Add a little white for the decalcification marks- in no pattern at all and viola! This is so simple and can have a really great effect.
ACTUALLY we don't but I thought this might get your attention and also it is a tribute to the patient in this case. Meet John he is a NASA engineer, a real rocket scientist and one the nicest guys you will ever meet. One day I actually bumped into him on a flight from Chicago to Denver and I asked him what he did at NASA and he said that if the astronauts utter those words "Houston we have a problem" he is the guy that they call. John lives in my city but works in Houston every week so he is only home on Friday - Sunday mornings and is a vibrant 75 year old man. You can see from his before photos that he has severe attrition/wear. He does not report any history of GERD or any intestinal disease. I had patched up a few teeth over the years and always discussed the need for FMR. He finally committed to the treatment.
The treatment plan given his work schedule and limited availability was to get a FM wax-up done, do the upper arch in one sitting and place over provisionals which he would wear for a minimum of 3 months to asses the new vertical etc. I TENS and took a bite and got the wax-up completed. You may notice from his before photos that his incisal edge position is actually not bad.
So we called in CADSmiles and he helped with the case since I wanted to get the uppers completed in one day and the provisionals in place on the lowers. Having him do the design and post-mill contour freed me up to prep the lower arch. Eddie has a great approach to these larger cases and they are divided into smaller segments all of which has been discussed on these forums several times. This case was done all with Celtra Duo LT A2 just polished and fired. Not going to win AACD and I did learn several things from this case but the patient was happy with the outcomes. The uppers have been in service for 1 year and the lowers were completed 7 months ago.
This was a case we tackled this morning. The patient wished to improve her smile. The plan was for crowns across teeth #6-11. At the initial visit last week we took impressions to have a wax up created.
The wax up is scanned into the BioCopy folder prior to the patients arrival to the office. Now COPY the contents of the BioCopy folder into the Upper folder. You will have exact duplicate data.
After the preps are completed. Use the cut tool and cut out teeth #6-11. Now image the preps starting slightly posteriorly and you will obtain a 1/2 stone and 1/2 human patient working model. Take the buccal bite and lower scans as well
After drawing the BioCopy lines the resulting proposal is a duplicate of the wax up. This has been a very predictable technique for me when doing my huge "Rhode Island makeovers" of 2, 4 or 6 anterior teeth. This was done in 4 hours. I'll post the finals after she stops hemorrhaging.
Here is a young woman, early 20s, that came in and wanted a bigger, brighter smile. She was asking for porcelain veneers.
I was hesitant to put veneers on her because she is so young and I didn't want to cut down her teeth if I didn't have to. She was already a B1 and had a great smile but this is someone who wanted Hollywood bright. I talked her into letting me do composite work instead. These I did free hand and I am so thankful for everything I have learned by using my CEREC that I could apply here. Could I have milled these? Probably, but the reason I didn't is because her contacts were so tight already that I thought I would be fighting seating these as a no prep, ultra thin veneer. If she would have had open contacts or even lighter contacts milling would have been an easier option. If I was going to mill them I probably would have used Enamic. They have the brightest shades available at this time as a hybrid. Instead I used Cosmedent Nano Plus composite, B zero. This is my favorite composite because of the opaqueness of it to give that bright look. I added composite on teeth #3-14.
She was happy when we were done, and I was happy that no tooth structure taken away. It was a win-win for us both ;)
Not too long ago my "CEREC assistant" moved to sunny California. I was happy for her on a personal level, but sad to see her go. She had worked with me for 8 years and she blossomed in her CEREC knowledge and training. Now I have had to refocus on training my other assistants and so I decided to make some easy flow charts for my lab to help out. If these can help anyone here than feel free to use them! PDF versions are printable.
Nothing fancy here. Typical case. Pt appointed for #2, #3, #15 direct resins and #5 crown. We scheduled 2 hrs and finished ahead of time; just over 1:30 (#5 Empress polish only; no oven time). I hope the following tips help you leverage your CEREC and complete more treatment in the same amount of time.
1. Anesthesia of upper right quad only. Next capture pre-op images of arch as I wanted to copy the B cusp of #5. Also image opposing arch.
2. Teeth #2,3 & 5 prepared. *Note that I did not spend time restoring the molars. As soon as the images were captured and we advanced to the model screen, anesthesia was delivered for #15.
3. You can use pre-op images to check your reduction if you're not using reduction burs or bite tabs.
4. Copy line of #5 that avoids the DO resin, hole in the occlusal surface & abfraction.
5. Initial proposal.
6. Overlaying images of pre-op and CEREC proposal.
7. Final design of #5 with unrestored #2,3.
*While the CEREC was moving from AQUISITION to MODEL phase, anesthesia was delivered for #15. No 'downtime' waiting for CEREC to process models.
*While #5 was milling, #2, 3 were restored and #15 was prepared for a direct resin (OL).
*Leaving #2,3 unrestored during imaging of #5 allowed me to disregard them when designing occlusal contact strength of #5 crown.
*After restoring the molars, I could adjust the occlusion of #2,3 while #5 was milling. Without the crown in place, I could disregard occlusion of #5 prep as there was none.
*After delivering #5 and cleaning the area, #15 was restored. As the upper right had already been restored/contacts adjusted and polished, I only had to concentrate on #15 when adjusting the composite.
Again, this isn't 'sexy,' just everyday bread and butter dentistry. My hope is that you'll find all the little areas of 'downtime' during a crown appt and find that there is plenty of time to complete other dentistry and make the appointment more productive while not increasing chair time.