I was out at Spear this past Thursday and Friday Mentoring Level 6a, and I got a lot of questions about Densah sinus bumps.

I have done several hundred of these over the last 3 years, and this method has been the most reliable with the least complications of any I've used.

Honestly, I rarely do lateral wall open sinus lifts anymore because I can make a guide and do these as a one stage with implant placement or a two stage where I graft first and wait.

This is a pretty standard case. I planned the Straumann implant short as we showed at level 6, drilled to the sinus floor, the used the 2.8, 3.5 etc Straumann sleeves to do the sinus bump fully guided. I drill clockwise (forward) direction up to the floor, then hit the switch for counter-clockwise (reverse for densification), and slowly pistoned with a lot of irrigation until I felt the floor give way. I did use some grafting material (Symbios hydrated in PRF) and gently moved it into the bump area using the Densah bur in reverse at 70 rpm. I then placed the implant, which went in at 45+ Ncm. 

The last image was at Stage 2, after confirming integration and placing a healing cuff. We went from 4-5mm of bone to 11+mm, in 3 months as compared to 6-9 months for a lateral wall lift.

The other advantage is that I don't need any new kits. I use the burs for normal osteotomies anyway, as they are essentially universal. No osteotomes, no balloons, etc. etc.

Keep It Simple!

Hey everyone.  Want to wish everyone a Happy Thanksgiving.  I'm very thankful for this community.  I wanted to post this today because many wonder how can CEREC garner referrals. I don't have the case photos yet but wanted to show the result of doing what I did from a marketing aspect.  We have a local Facebook group here in lake forest with some very active members.  One of them is a die hard pt of the practice.  Her daughter was getting her braces off last Friday and has a congenitally missing #7.  They were going away for the holidays.  I talked about doing a Maryland bridge,   well she thought with the timing of the holiday and the office booked solid, that her daughter would be wearing her flipper.  I decided to come in on a Saturday to see her daughter and make the bridge so she could enjoy the holidays with a permanent restoration.  She would then go back to the ortho on Monday to get a new retainer made with the bridge in.  I made the bridge that sat morn.  By Sunday morning there was this post on our local Facebook page

On Tuesday I got a call from the ortho saying so many nice things about the treatment we did for this kid while she is waiting to be old enough to do an implant.  Now I have the people in my town who follow our Facebook page know that we go out of our way for our good patients and I have a specialist that was so impressed with the technology that he'll be sure to send families our way knowing what we can do.  CEREC is an amazing technology.  Use it to all its advantages!

This summer I had the opportunity to go to a women in leadership meeting held by Dentsply Sirona where I met some amazing and talented women. I have been working hard to get them to post their cases but it has been a little intimidating for them due to some previous experiences so I asked if I could share a few of the cases that get sent my way. It is intimidating to share work that you created yourself because you have to own it and often we pour our heart into our work.  This is the only way though as a community we can elevate ourselves and other clinicians by sharing our work, encouraging other,s and offering constructive criticism when needed. It has been disheartening to see some of the bashing that happens online on some of the Facebook groups and that is why I am so proud of the community that we have all created with cerecdoctors.com.

Look at this work!!! I was blown away. Just to be clear- These are not my cases. I would be so proud to show them as my own, but I get no credit for this talent.

Case 1- e.max crowns #26 & 27

Case 2- Empress veneer #8

Let's show these talented doctors that posting your cases doesn't have to be scary. Show your support, and if you have feedback they are hungry for it, but just be kind in how you present it please ;)

I love to use Maryland bridges as long term temporary solutions. Especially when kids are getting out of ortho and not quite ready for implants. The most difficult part is typically the connector for these types of cases. A great tip I just got at CERECdoctors.com to help with this is to design the Maryland Bridge with the connector as an intersection, get the connector to about a 3, and then go back to admin phase and switch it to anatomic. This will help bump up the connector automatically to the needed size without the ridges that anatomic normally gives (I believe it is called the Fleming technique ;)). It was a great tip that helped speed up design. That is just one more reason why I love this group. Even coming to the courses to mentor, we can always get great tips!

Here are a few examples of some fun Maryland Bridge cases with kiddos. These can be done with the wing on the facial or the lingual and there are examples of both. This is dependant on the bite. What material I use is dependant on the amount of time and the amount of characterization that is needed. If the restoration needs to last less than a year, and I don't need to prep anything, then I love using GC Cerasmart. If the restoration needs to last several years, I have personally found that e.max tends to last longer. I do warn my patients and parents that these can fall off. It doesn't happen very often, but when it does it is only at the most in-opportune times. The good news, it's very easy to recement it and typically there is no damage done. They still love this solution much more than a flipper. 

1. This is an interdisciplinary case with my orthodontist and periodontist. Her centrals were hopeless due to trauma but placing two implants next to each other can be really difficult to restore. We extracted #9, moved #10 into the #9 space and are holding on to #8 as long as we can until she is ready for implants (hopefully). She is 15 yrs old at this point.  

2. Post ortho, a young man missing #9 due to trauma. He is 16yr old and still growing and could not stand having a flipper.

3. A young man congenitally missing #10 and also too young for an implant. 

I decided to mill this instead of building it up by hand for this young woman. It milled in 6 min and then I added color tints and a thin layer of microfill of the top to seal in the color tints.

This was one of those cases that was just fun for me to do ;) I might have gone a little intense with my translucency stain but overall I think it blended pretty well. She was really excited to not have the dark tooth anymore. Just something a little different!

Just wanted to present a fun and interesting case that I just completed this week on a wonderful English gentleman.  He presented about 1 year ago with failing RCT's and resorbed roots on teeth 8 and 9:

After discussing options, it was determined that extractions and implants would be the best plan.  We discussed gingival zenith issues, and due to a low smile line and him not being concerned about it he did not want to pursue excessive grafting with the surgeon.  He asked if we could space out treatment a bit, so we began with #8.  I fabricated a flipper for him(which he hated) and sent him to the oral surgeon for extraction and grafting.  A few months later, on the day of his implant surgery, I received a call from the oral surgeon, and he mentioned that our patient was asking if we could put a tooth in so he did not have to use the flipper any more...the surgeon informed me that he was comfortable with the insertion torque and that I could place an immediate provisional-and they sent him right over!  Time to scramble...the OS placed a Nobel Active 5.0 so I placed a scanpost and imaged:

We then milled out a Vita Enamic IS block, left it out of occlusion, and undercontoured the facial in the gingival 1/3 to avoid gingival pressure.  Unfortunately, because of the lack of time to prepare properly for this curveball, the only shade I had on hand was 1M1:

Now, this is part of why he is awesome-when I told him the tooth was too light, and that we could mill another one later, he told me he loves it(he would have loved anything to get rid of the flipper) and that he would stain it down with Earl Grey!

A few months later, he went back to the OS for removal of 9, and this time the OS did an extraction and immediate implant, and informed me that I could place an immediate temporary in this site as well.  When he returned from the OS, sure enough he had worked #8 into a better blend!  We then fabricated an Enamic IS for #9 and let the patient heal:

Now, please note that #8 is slightly longer than #9-the reason for that is...well...I hadn't noticed in the process of the appointment.  No other real excuse:).  A few months later, he returned for the next step in the process.  Now, with the access holes through the facial, I clearly knew I needed custom abutments, so this seemed like a perfect time to try out the Atlantis workflow.  Note how nicely the gingiva responded to the temps:

We placed the IO FLO scanbodies and imaged-you can tell the funky angulation of the implants in the scan images:

Within 24 hours, the following file was available for my review:

So, bounced that over to my buddy Dan Butterman, who suggested some minor edits for me(thanks Dan!).  He also pointed out that it did not have me set up for gold hue abutments, which I thought that I had requested-so make sure to double check when ordering...they very quickly sent me an updated plan, which I approved:

Now, one lesson I learned is that when imaging the IO FLO scanposts, the scanbody folder should be well-imaged.  I had scanned similar to a chairside case, where I capture a clean image in the maxillary arch folder and then the detail of the scanpost and enough data to stitch, but when they sent back my Core file an area I had not imaged well was causing an issue:

Reached out to Atlantis and they sent a corrected file, but just another thing to watch out for.  After a couple of days, I received my abutments and used the file to design and mill out my crowns.  It was a very easy process and all we had to do was design two crowns.  They fit the abutments perfectly, which was pretty cool to see:

Finally, delivery day, after the patient returned from a trip to China, where he informed me he drank enough tea to take everything down another shade or two.  The Atlantis abutments fit perfectly, without any discomfort for the patient.  He was right about his trip-the crowns were a little too light initially so we refired them with some additional stain to bring them down a bit:

Final crowns were e.max A-2 MT.  Obviously, the gingival heights ended up asymmetric, and I missed on the DI line angle of 9.  We had one fun exchange along the way where he told me "I don't want perfect teeth-I am English."  To which I replied "Then you came to the right dentist!" This was a fun case, mainly because he was an awesome patient, but also because I got to use the technology in such a variety of ways...always amazes me the flexibility and options CEREC gives us, and this Atlantis workflow was really incredible.  Thanks again to Dan for taking a look at this case to help me get on the right track!

Brasseler U.S.A. Dental, LLC Introduces New Procedure 

Systems Developed with Cerecdoctors.com for CAD/CAM Users

Convenient and comprehensive solutions for CAD/CAM restorations

SAVANNAH, GA (October 12, 2018)– Brasseler U.S.A. Dental, LLC (Brasseler USA), a leading manufacturer of quality dental instrumentation, is pleased to announce the development of new procedure systems for use in CEREC® procedures with cerecdoctors.com.  These new procedure systems incorporating Winter Restorative Concepts, a line of diamond burs and refinement instruments by Dr. Robert Winter, now provide clinicians end-to-end solutions for the preparation, finishing and polishing of ceramic CAD/CAM restorations. 

Brasseler USA CAD/CAM procedure systems are available in:

• Anterior and posterior tooth preparation systems featuring the Winter Depth Limiting and Winter Shoulder Series of diamonds.  These diamonds provide clinicians minimally invasive, precise preparation design ensuring more predictable outcomes for CAD/CAM dentistry.
• An intra-oral ceramic adjustment and polishing system as well as an extra-oral ceramic adjustment and polishing system featuring the Dialite® LD Feather Lite™ series of polishers.  These polishers provide clinicians with flexible polishing spirals that easily adapt to any surface, leaving behind an enamel-like finish while preserving unique surface differentiation on ceramic materials, including Zirconia and Lithium Disilicate.

These procedure systems are used and taught by leading dental professionals including Spear Education and cerecdoctors.com.

For more information about Brasseler USA’s extensive product and service solutions for all dental, hygiene and laboratory professionals, please visit https://shop.brasselerusa.comor call 800-841-4522.   

About Brasseler U.S.A. Dental, LLC

Brasseler U.S.A. Dental, LLC (Brasseler USA) is a leading ISO-certified healthcare company, providing quality instrumentation to healthcare professionals for use in restorative dentistry, endodontics, oral surgery and oral hygiene. Over the past five decades, Brasseler Dental has developed a reputation as an innovative market leader in diamonds, carbides, polishers, endodontics, hand instruments, and handpieces. Today, Brasseler USA offers the most comprehensive assortment of dental instrumentation under one brand in the world. For more information, please visit www.BrasselerUSA.com.

First case here - very nice work flow for sure.  Hope they will keep the cost down for it to make sense for us to utilize....have more in the works will continue to post as I know others have more experience.  Any questions welcomed.....

This case was pretty fun that I just finished today:

Patient wanted midline diastema and rotation fixed and also stated that she really did not like the translucency of her edges:

I scanned her at the hygiene appointment, designed two NO PREP Tetric CAD veneers over 8 and 9, and 3D printed a model to fit them on:

We bonded them in today with Variolink Esthetic light and did some minor bondings on 7 and 10

I suppose I could have done with ceramics and the esthetics would have been a touch better, but no way could I have milled them this thin.  I'm liking the idea of Tetric CAD MT as a no prep veneer material

I don't get to do a lot of bleach shade cases in my neck of the woods so I am always a little surprised when I actually get the chance. Whew! They are bright and they are white!

Here is a woman who wanted some new crowns due to recurrent decay and she felt they were too yellow. My camera does not do the existing crowns justice. They were a B1!

Her concerns with her previous crowns:

1. #9 was longer than #8.

2. The incisal embrasures between the laterals and centrals were too open.

3. She also didn't like the "black pepper" look between her centrals. #8 and 9 had previous endo.

4. Her crowns were too yellow and she wanted to match her "new crowns" on upper right. 

5. Her crowns were all different opacities- #8 & 9 were lava crowns, where as the others were e.max done at different times.

Her plan is replace her lower anteriors next year as well as her upper left crowns. 

Here is what I love about my CEREC. This case was pretty easy because all of the hard work was already done for me. I could have done this either Biocopy or Biogeneric Individual. Personally, I chose Biogeneric Individual purely because doing the copy line is an extra step and takes more time. I do however add the Biogcopy folder in the acquisition stage, and scan the existing crowns so that I can use this as a reference point for midline and incisal length. I also have my checklist of things she didn't like and can correct that by ghosting the Biocopy model over my proposals. She did not want a lot of characterization in this case as far as staining, because she wanted Hollywood white. My rule of thumb on this is, the less staining the more contouring. It's how I can get them to pop.

This is a case I chose to do same day. Why? Because seeing one patient vs. 15 is very calming to me personally, and also because when I leave my office, I don't have time to come back and do lab work. The one visit is my scheduled lab time. This is also how I market my practice and I am comfortable with that. My husband does cases like this in two visits because for him sitting with one patient is the exact opposite of calm. He would much rather do this on his own time with no pressure of time. Is there a right way? Yes, of course- It is always the wife's way!!! (just kidding- the right way is whatever you are comfortable with!)

The new crowns are e.max BL 2 MT crowns. I needed a touch of opacity to block out the RCT on #8 and #9. 

Happy CERECing!! 

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