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Richard has been a patient of mine for the last eight years. He’s 32 years old, single, and an overall great guy. Earlier this year he made a consultation appointment for his front teeth to discuss veneers. When we finally sat down, I asked him what made him decide to move forward with this treatment. He mentioned that he was tired of being single and knew that he needed to do something about his smile if he wanted to feel confident enough to enter the dating scene and find a life-long partner.
We had a lengthy conversation about what he wanted to be sure I could meet his desire. His request was simple: make is teeth white. Overall, the position of the teeth was good; no ortho or soft-tissue treatment was required. As this was a straightforward case and the patient wished to begin treatment as soon as possible, I elected to begin without a wax-up. While this is not my normal protocol, I felt confident I could deliver and the patient would be happy. A pre-op putty was taken and his teeth prepared.
CEREC images were captured and the putty was used to fabricate the provisionals. Even though the temps were the same shape/position prior to preparation, he was quite happy at the fact that his teeth were no longer discolored. Without a wax-up to copy, I decided to send the case to Weston Hatcher and allow him to design it. Weston and I spoke about the case and I let him know what I was looking for regarding facial anatomy (minimal to none), embrasures, etc. The final design was emailed back to me a few days later and the restorations were milled in-office.
After the congratulations, handshakes, and hugs, I walked him to the front door. When he walked outside, he raised his hands in the air Rocky Balboa style and shouted, “I’m beautiful!” Cases like these make all the tough days hard to remember. I wish the young man well in his social life with his new-found confidence. These restorations are Emax BL4 and were hand polished only. I chose not to add any incisal or cervical characterization as the patient’s primary desire was to have teeth that were simply one color.
This was patient had trauma to #7-9 many years ago, neglected her teeth and presented with gross decay and fractures. She wanted a new smile and insisted on doing this in a single visit. The software did a really good job with biogeneric individual proposals. These are 7-10, Empress Multi A1, polish only. I really prefer to not have the anterior's too glossy, when wet, they look very natural. Since I have 2 mills, the entire treatment was completed in just a few hours.
With all the recent interest in Azento and Astra EV, I thought I'd share a case with a couple of tips to help you avoid a couple of complications I encountered during a procedure.
In this case, the patient was referred for an evaluation with suspicion of a fracture; the referring doc was unable to do find the fracture, and after I looked at her I could not locate it either.
I sent the patient to my excellent endodontist, who after accessing was able to find a fracture on the distal and returned her to me with a hopeless diagnosis for #30. We went through the now routine and simple process of capturing CBCT and CEREC digital impression, and uploading them for Azento case analysis and production. With the available interradicular bone, I opted for an immediate placement. Azento digitally removes the tooth and designs the guide as if it were already extracted. As this patient would be returning to her referring doctor for the final prosthesis, I chose the custom healing abutment solution only. When the patient came in for surgery she looked like this:
Obviously the guide won't fit with the tooth in place, so the first step is to perform a coronectomy. I will typically use a 557 carbide to undercut the tooth following the gingival contours, first from the buccal and then from the lingual until the clinical crown becomes mobile. My assistant will keep the surgical suction on the occlusal of the tooth to keep it from relocating to new territory in the lung or gut. Once the clinical crown is safely gone, I will use whatever large coarse diamond is on hand (either a large football or an 845KR) to finish it down to where the guide will clear it. Try not nick or abrade the soft tissue too much as you do this.
I prefer to complete the osteotomy with the roots in place; there are a few excellent threads detailing this process here on the boards. One of the benefits of this is that the distal curve of the mesial root that many mandibular first molars have is obliterated during the drilling process. This particular root is often the cause of difficult or complicated extractions. Once the osteotomy is complete, it's usually a fairly simple process to remove what's left of the roots and then thoroughly curette and irrigate the site with saline. When curetting the socket in cases like this one where there was some periapical pathology, spend as much time as necessary to achieve clean, bleeding walls. Once that is done, the implant is placed through the guide to the appropriate depth and orientation to accommodate the custom healing abutment; remember that one of the benefits of using EV and an Atlantis custom abutment is that the abutment fits only one way, and the guide helps you position the fixture so that it is timed correctly. Once the implant is placed (in this case we achieved approximately 25 Ncm on implant insertion), a good practice to follow is placing a cover screw while grafting the gaps around the fixture so that your graft doesn't occlude the internal aspect of the implant. In this case I used a cortical/cancellous mineralized/demineralized blend allograft, mixed with PRF, to graft the gap. Then I used a PRF "membrane" with a hole punched in the middle to drape over the graft. The hole is there for the healing abutment to go through, but if you undersize the hole you will see the PRF membrane distort as you deliver the abutment through it. The final step here is to suture, and in this scenario I will typically start with a horizontal mattress to pull the buccal and lingual gingiva against the healing abutment and underlying graft as much as possible, then follow with a pair of single interrupted sutures to tuck in the papillae.
I ended up having to remove the healing abutment after the PA was recorded, as it was clearly not seated all the way. I used the larger bone profiler so I felt confident that was not the issue. Turns out despite the care I took to exclude graft material, one tiny piece migrated into the implant in the short time between cover screw removal and abutment placement. Always double check this as you're moving forward; not fun thinking you're pretty much done and then having to go back. This lead to another minor complication: when I put the healing abutment back on and hand tightened it, the PRF membrane distorted a bit and the implant/abutment complex rotated a few degrees. This is one of the aspects of using the Astra EV that can be technique sensitive; the threads of this fixture are not particularly aggressive. While the bone implant contact is very high in a normal osteotomy, and it is very important to keep the insertion torque value less than 45 Ncm to avoid pressure necrosis, the story is a little different in immediate cases. I used the V drill to finish up the osteotomy as I routinely do in most of my EV cases, and in hindsight this is where I erred. Since the implant is only partly fixed in bone, we need the torque value higher (45Ncm) vs the 20-25Ncm I ended up with after using the V drill. If you place the implant and are exceeding 45Ncm, you can always back it out and alter the osteotomy with the V or X drills, or the A or B drills, depending on the clinical situation. Once the bone is gone, however, there's no easy or predictable way to get that torque value back up. I was concerned that trying to reverse the complex simply to make the healing abutment straight or to make the PRF drape ideal might reduce the stability to where the fixture would fail, so I opted to leave them both.
The patient healed normally and had no further complications, and the referring dentist had no issues restoring the fixture.
I'm hoping the small errors I made with this fairly routine case can help some of you as you adopt this treatment modality and explore the varied uses of Azento and Astra EV.
I know there has been quite a bit of discussion on the boards in regards to the Azento procedure, costs, etc. But, every time I restore one of these cases I am so impressed.
This patient presented with a symptomatic #19 with existing RCT. I explained to the patient that the root canal was failing and our best solution was to restore the area with an implant.
The PA really didn't communicate the area of infection to the patient.
But, this is why I love having the CBCT in the office. The ability for co-diagnosis with the patient is much easier.
The tooth was extracted and socket preservation was completed with prf, sticky bone, and long term resorbable membrane.
Pt returned 6 months later and was scanned and Azento was used for the planning process.
I really like the design of the guides with Azento that allows for the window on the lingual. Access with the drills when performing the osteotomy is greatly improved.
The procedure is so slick with the keys being built into the the actual drill. Start to finish this case took around 20 min.
The best part of this procedure is the restorative component.
This patient returned this morning. The custom healer was removed and the custom abutment was placed. There was no need for anesthesia or releasing incision as the custom healer and the custom abutment have the exact same emergence profile.
Using the core file we were able to mill the final restoration before the patient came in to have the final abutment placed. The fit is excellent.
The new pricing structure with Azento and the efficiency associated with this procedure, now makes it a no brainer for me.
Some years ago I kind of desisted to do more than 2-4 anterior or cosmetic cases in the office. For time, results or whatever reason. Since prime scan came out, I started to push its limits and that along with the evolution last years in digital design, 3d printing evolution has encouraged me to do this cases again in the office, with a little help of a DT friend of mine we have been doing this cases lately with very nice results. Saving lots of time and money without sacrificing results.
So basically we take all the data, scans, (prime/3shape) pictures. The digital wax up is done either Inlab or meshmixer. Print for mock up/temp, prep and biocopy (nothing new about that. I also take a quick pvs to finish up contacts and adjustments, also print a resin model. This case was done with empress multi BL3
I’ve seen a few posts lately regarding the OptiSleep oral appliance and wanted to give a general overview of how to use the Sidexis software to segment the airway, import the necessary CEREC data, and ultimately order the OptiSleep device.
Once a CBCT volume is obtained, selected the TOOLS tab and then select SICAT SUITE.
Once on the SICAT AIR page, select the ANALYZE tab. Please note the blue, vertical arrows. The single arrow is used when you wish to segment one airway. If you wish to compare airways, perhaps after treatment with the OptiSleep, use the icon with two blue arrows.
In this screen, you need to identify the patient’s airway. I selected a spot on the hard palate and double-click to begin the segmentation and then drag my cursor to the bottom left, somewhere on the patient’s spine. Again, double-click to end the segmentation and form a box denoting the patient’s airway. The software will trace out what it believes to be the airway and highlight this in yellow. Just like when we merge CEREC & CBCT data, you will need to confirm that the segmentation is correct before proceeding. If you are satisfied with the tracing, hit OK.
The software will complete its calculations and you will now see a 3-D model of your patient’s airway, complete with coloring. The parameters for the colors themselves can be adjusted, but that is far beyond the scope of this post. IMPORTANT!! This software cannot diagnose obstructive sleep apnea. This representation is merely a conversation starter with your patient. Only a sleep physician can diagnose your patient with obstructive sleep apnea (OSA).
Your patient has OSA and can be treated with an oral appliance. Consent forms are signed, finances secured, and the patient is ready to have an OptiSleep oral appliance fabricated.
Full mouth CEREC images are captured, as well as a bite registration obtained using a George Gauge.
The patient’s CBCT is opened, and the ORDER tab is selected. There is an icon that resembles teeth and that should be clicked to begin importing the CEREC images.
Again, similar to the workflow when importing CEREC data into the Galaxis software, you will BROWSE your computer and import the correct CEREC images.
Both arches will be imported. An order will be created and placed.
I hope this helps and please remember this is a generalized overview of the process. Remember, CEREC Doctors has a wonderful seminar on Airway Prosthodontics if you’re looking to go down this path.
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 ;)
This long time patient had been self conscious for years with her diastema and ugly crown/tooth size discrepancy. 14 months of Invisalign and a new crown and 3/4 crown on #9 and she is happy and smiling.