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Inventory. It's a love hate for me. I love to try out new materials and have lots of material choices and have all the shades under the sun.
But as a business owner who is trying to run a successful, profitable practice and set the tone for our doctors, I need to be smart.
When I first started using CEREC, I saw post after post from doctors warning us against using IPS e.max HT. If you do, you will get the dreaded "grey" crown. As many of you have seen, I do a lot of HT in the anterior, for crownlays, and if I'm trying to match a patient with a C-shade. In my eyes, C shades are just a lower value of A shades. Sometimes we just say the tooth is "grey" but on the flip side, we can use this to our advantage. If I see a lower value, C-tones or "greyness" in a tooth, my thought isn't to pick a C-shade, it is simply to use IPS e.max HT.
Here's my rationale. It keeps my inventory simple. As I already stated above, I have a lot of uses for the HT block. One of the other qualities of an HT block is that the value can be dramatically affected by the color of your cement. For a case like this, I can use this to my advantage by understanding the nature of qualities of my block on hand. People have argued that I should just pick a C2 or C3 LT block and that is just easier. I look at it from the other end of the spectrum in that using the HT block kind of bails me out if I don't choose the exact right shade. Let's look at this case.
I put the A3.5 shade tab up just to show the lower value of the teeth compared to the tab
This is a case that I see C-shades and automatically think about HT. I told my assistant that we would be doing A3 HT and that she would be doing the rest. I'm really been trying to train up my team members and not do all my stain and glazing.
Below are the Pre-Op, Try-In and Delivered Crown. All we had was A2 HT left, so this made my assistants job a little more challenging with staining down this crown to get it to match. I told her to use a little of the e.max "1" stain for the gingival 1/2, some of the I-2 stain for the cusp tips to drop the value down a little more and to add some white to create some craze lines. Overall, she did a good job with the staining. At Try-In, the value was too bright for my tastes though I wasn't trying to match the "darker" canine, I still wanted to lower the value down more. If I had done the C2 or C3 LT block, the different color resin cements wouldn't make too much of a difference. In fact, the thicker your porcelain, the less of a difference the colored cements make. As you can see from the photos, the occlusal of the tooth is relatively unaffected from the Warm + cement.
There isn't anything too incredibly special about this case, but wanted to share some things I've learned about IPS e.max HT and how I use it. I hope this can help others not be intimidated by the block and utilize it when appropriate.
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!!!
Fortunately our chairside options for bridge blocks is growing. With Ivoclar Vivadent coming out with some blocks, 3M and Katana Noritake will be releasing there STML bridge block later too. Originally I used to push the limits with IPS e.max bridges with the B32 block. I had one failure with connectors that were adequate 18mm2 but they were short. Now I tend to only do IPS e.max bridges if I am doing an anterior case or a premolar pontic.
So here is a case that I just did with CEREC Zirconia A3 in the medi S block. The challenge with CEREC Zirconia in my opinion is the opaqueness and the high value. For me, I'm always trying to tone that brightness down and give the restoration more depth of color. What has worked well for me is infiltration stains from VITA and then stain and glaze to follow. Here is a lower posterior bridge that I just delivered. After design in the software, I used my infiltration stains and then did 45 minutes drying and sintering cycle.
I bought the Zig Detailer Brushes on Amazon for like $5/each.
After the sintering cycle, I fired the case on P4 with Empress Stain and Glaze. I used a bit of Mahogany in the grooves and for the embrasures. A little bit of A shade stain for the gingival aspect. Added very little Incisal 1 (Blue) for the translucency for the cusp tips. And then white to create accents and highlight the other colors.
Overall this case isn't perfect, but I think it is a good option for us chairside. As an aside, I did this case in two appointments. Milled the provisional bridge with 2M2 Vita CAD Temp.
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Scan, approve, milkshake treat
This patient has secondary decay under a pfm that is critical to the stability of his partial. Both the crown and partial were done just after the Korean War. He loves his partial. These cases are always my favorite. Think back to how we used to handle this workflow in the analog world. Pick up impression and take the patient's partial away from them for a week. They would then hibernate until we gave it back. The lab crown would never fit to the partial so we become human milling machines and try to adjust to fit. Bend the clasps. Break the clasps. In the end we end up with a barely acceptable outcome and offer to make a new partial.
Last week I talked about the importance of planning the implant restoration prior to doing surgery, in order to avoid complications.
I want to take it a step further, it's equally important to export the crown design as an .SSI file and import it into Galileos Implant for planning. This patient has multiple missing teeth, and agreed to implant treatment @#12. If I would have only planned the implant in my CBCT planning software, without regard for the restoration, it would have been a restorative nightmare.
I posted this case on Facebook yesterday and I thought I would post it here as well.
Patient came to my office (works in the dental field) and was concerned about the wear on 8 and 9.
Now from first look, it seems as you might be able to be conservative with composite. However, we have to understand "how" the wear was caused... In this case her older lower bridge was a bit too long incisally and causing "pathway wear" on the lingual that also damaged the incisal edge. If you just simply add composite, it's likely not to fix the underlying issue.
The plan was to do full coverage crowns on 8 and 9. Why full coverage crowns? Because I wanted to both lengthen the teeth, restore proper lingual contour, and slightly increase overjet to give her more room to function... we also planned on lowering the incisal edge on the lower bridge
Step #1 was to quickly mockup with composite. We mocked up both the incisal edge and the lingual surface. By doing this, the occlusion was obviously very high... This gave me a roadmap on how much to reduce the lower bridge:
Here are the preparations and scans with Primescan:
We chose to do Biogeneric using the "mockup" as a guide... we chose a Vita Morphology in the database. Here is the "biojaw" proposals and final designs:
And here is the final result...Vita Trilux Forte
I'm always amazed how often surgeons only look at bone when planning implants and spend little time looking at the future restoration. Carl Misch used to say that no one wants implants, they want teeth. This patient was a second opinion for an implant to replace #11, he was already scheduled for the implant in another office, but his wife is a patient and asked him to see me first. The surgeon told him this was a very straight forward implant case.
The first thing I do on every implant case, even before taking a CBCT, is scan the edentulous site, draw a margin, and get a crown proposal. If I see a problem with the proposal, the patient and I can have a conversation about how to move forward. This patient had plenty of bone for his implant, but he has some choices to make about creating room for the restoration. The point is, we can talk about it before surgery. I'm a firm believer in anything you tell the patient before treatment is an explanation, anything after is an excuse.