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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.
I've posted about this before, how CEREC can help you complete an RCT, b/u, APC in one appointment, often in under 2 hrs. My last post on this topic only showed the before and after photo; no intermediate steps.
In an effort to explain the process further, I performed the same treatment on tooth number 15 and took photos along the way using my Primescan.
Here are my steps:
- Anesthesia, CEREC images of opposing arch and buccal bite. I capture the buccal bite at this stage as the patient has not lost proprioception in the area.
- Place IsoDry and begin preparation of the tooth. I begin with occlusal reduction and then move on to the decay.
- Once I have clean margins and I’m at the pulpal floor, I placed a Tofflemire matrix.
- Build-up complete.
- Final preparation. It took me 25 minutes from the time I picked up the handpiece to this point.
- CEREC images are captured and I have a second assistant design, mill, fire the restoration while I drill through the center of the build-up & complete the RCT.
The beauty of this approach is that simultaneous processes are occurring. By reversing the typical RCT-crown order, I was able to complete treatment in under two hours.
Side note: my CBCT allowed me to visualize the number of canals (no MB2) and and their paths prior to initiating the RCT. I knew prior to starting that the palatal canal did not go to the apex of the root. Had I not seen this ahead of time, I may have thought my obturation was short in my final PA. The power of these technologies cannot be overstated. They have allowed me to provide better, more efficient treatment for my patients in a consistent manner that I never thought possible before.
For those that have been on the fence with Primescan, or have not tried the Atlantis workflow, I thought I would share this fun "real-world" case we just finished recently. These are my favorite types of cases, where we can really make a difference for someone. Patient presents as an 80 year old woman who was wearing an ill fitting partial for awhile and was losing weight because eating was very difficult. She has some significant health issues and was told in Florida that she "could not have implants", which was obviously inaccurate. She saw an oral surgeon who we work with for placement of three implants and he bounced her over to me. Now, there are certainly plenty of other restorative concerns, but we wanted to address the immediate issue and get her back in function. Here is how she presented:
You can see in the next pic that she has a tight upper lip that we were fighting with, which made photos a challenge, but it also helped us restoratively because she had a low lip line and there was significant atrophy in the area over time. We debated pink porcelain over longer teeth, but as you will see in the finals it really didn't matter esthetically due to the tight lower lip line. But, most importantly, I love how the Primescan picks up everything, including the metal on her partial:
The double buccal bite made sure we were able to get a stable model:
Check out the depth of scan, into the implants:
So, we placed the IO FLO scanbodies and took our scans:
Love how it even captures the clasps-ridiculous. So, we sent the case to Atlantis and had them fabricate the abutments...they were able to parallel everything and send me the plan:
I approved the plan and they sent me the abutments and the core file for the bridge-I was able to take that core file and send it via connect off to the lab-so at this point I have not taken a single physical impression or touched a model, but we have abutments and a final fixed partial denture being manufactured. I also remembered this time to order the seating jig from Atlantis-makes life so much easier:
So, once the bridge came in from the lab, we had the patient come in. Popped in the seating jig and delivered the abutments in a few minutes-such a smooth process. There was blanching of the tissue but patient was never uncomfortable, and it went away after a few minutes:
Delivered the final bridge and we had a very happy patient:
She called me the next day all excited about how she went out to dinner with her husband and was able to eat...in the world of Italians, that is priority number one! All kidding aside, it was great to use the amazing technology and Atlantis workflow to tackle a challenging case and help her get healthy. Impressions would have been very difficult, but with Primescan it was unbelievably easy. Now, she is so excited she wants to start addressing the other areas as well...fun times in dentistry for sure!
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.
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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.
***And no, I'm not referring to the girl or guy you picked up at the 2am dive bar last weekend.
Of course, we're always chasing perfection that doesn't truly exist, but there are clinical scenarios where achieving a level "10" outcome is impossible. The following case is one that I took over after implants #7, 8, and 9 were already placed and after the patient had become frustrated with multiple try-ins of the final implant restorations at another office. The esthetic problems were numerous and the placement of the implants posed a significant challenge, so I was careful to under-promise when discussing possibilities with this patient. Ultimately, she took the "it couldn't possibly be worse" approach and allowed me to re-design her smile. So off we went...
With an approved FGTP template to guide us to the end result, I did a quick physical wax-up to estimate the midline correction, performed crown lengthening #5, 6, 11, and 12 to bring their gingival zeniths apically to closer match the soft tissue around the implants, and provisionalized #6-11.
After 6 months of healing, we finally moved on to the final restorations #6-11 via Biocopy of the provisionals. We had to fight dark teeth, unfavorable implant angulations, and even needed some Juvederm to coax the flat gingival architecture into some semblance of a scallop. It was a ton of effort just to get a "7" result for this awesome patient who has truly been a "10."
This patient presented with a "loose" tooth, c'mon man
Plan was to extract the tooth and let the soft tissues heal up a few weeks
Took full arch scan with Prime, printed 3D model an essix retainer with a tooth for interim partial.
CBCT and full arch scan sent to Azento for treatment plan and below is final plan:
Time to execute the plan - I only ordered a custom healer on this case, no final abutment
I did flap this case to make sure the guide was seated completely and to make sure things were seated correctly given depth of implant
Happy with the outcome, I am certain there are several ways to handle a case like this - always looking to improve so any feedback is greatly appreciated.
Will finish the case with an atlantis abutment and final restoration - one option I really wish Azento had was the option to place a "later order" for the final abutment on cases in which you did not pre-order all the prosthetics so that I could asses healing and then just do that rather than having to take another digital impression.
Something that I've picked up through the years from Sam, Flem, Skramy and my wife, Kris, is that natural teeth have a lot of white in them. When used well, I've found that it can make teeth really look a lot more natural and will give a monolithic restoration a lot more depth. I use white to add decalcifications, mimick craze lines, enhance translucency and oftentimes, it is just what the case needs. I will say this takes a little practice and it is easy to not have enough or too much. For a few of the cases that I will show, I really think it adds a little extra and makes the restorations blend in better. For many of you that see my posts, I often will use the Empress Stain and Glaze Kit on my cases because of it's ease of use. (For IPS e.max, make sure you have the restoration crystallized first if you are going to use Empress Stain and Glaze).
1st Case: VITABLOCS TriLuxe 1M2-A little sunset color stain gingivally but the rest is subtle white striations
2nd Case: Empress Multi B1 #9-This is an off angle pic but really showcases using white enhance the restoration
3rd Case: The before is the classic monolithic crown without anything. I used VITABLOCS Mark II 1M1 and just added glaze and some white to attempt to match the white spots
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.