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A 60 year old mother of the bride decided on a whim to fix her cracked crown before this Saturday's wedding.
A neighbor of hers told her that I could do it in 1.5 hours at their neighborhood Halloween Party on Saturday night. She called this morning and we squeezed her in.
EMAX B1 MT.
No heavy characterizations or stainings were needed in order to match the old PFM's. We've got one happy and excited Mother!
It never gets old!
It's such a great time to be in dentistry; technology and education are helping us to provide an increasingly high level of care for people, and it's such a gratifying experience. For example, taking a digital impression instead of a traditional one; the consistency, accuracy, time and cost savings, and patient experience are all terrific upgrades. CBCT technology is another great example; the incidental findings that we never would have located with 2D radiography, the increased awareness of the "whole person mindest" (thanks, TK!), the ability to make decisions on a more complete set of data, are all game changing! CAD/CAM abutments and restorations have allowed us to increase accuracy and efficiency in so many aspects of our dental lives. Dental implants have progressed in research supported design and have become a key part of the modern dental practice. Lastly, the high quality of education available to us in support of each of these examples is key to making the most of them all. Each of these are valuable in and of themselves, but by combining them they become truly advantageous to our work, and more importantly to our patients. Here's an example of one such case:
The patient was referred for implant therapy in the #19, 20, and 29 sites. Prior to CBCT, guides, and excellent clinical training, I would have considered punch access, placed 3 implants with healing abutments, all using a pano and with no regard to what was happening with the soft tissue, notably in the #19 site.
I took a digital impression, designed the future tooth positions for all 3 sites (a true prosthetically driven approach), and merged that data with the CBCT. Seeing where the teeth are supposed to be in function certainly helps to plan the correct implant positions. After all, the point of the implant is not the implant, but what eventually goes on it! Seeing the big picture in this way almost forces you to consider things such as occlusion, spacing from teeth to implants and between implants, and also soft tissue challenges, as indicated by the arrow.
Being able to see the case 3 dimensionally really helps your understanding of the clinical realities facing you, and being able to perform a virtual surgery that is prosthetically driven is also a boon. Even better is being able to reproduce these planned positions with precision using a surgical guide. Trying to achieve a copy of your virtual plan using free handed surgery is exceedingly difficult, and does not serve our patients when techniques exist to help us achieve ideal outcomes. In this case I ordered a SICAT Digitalguide and printed it in house with a Formlabs 3D printer.
Because of the virtual surgical planning, coupled with surgical education, I knew I could place the implants without bone grafting, but I also was aware that I would need to manage the poor quality mobile tissue that would be against the buccal of the #19 implant if I did nothing. I repositioned 3 or 4 millimeters of thick attached tissue from the crest to the buccal; there was some suturing involved after this photo with the healing abutments.
The combination of soft tissue management, correctly positioned fixtures, and an implant system (in this case, Astra EV and their BioManagement Complex) designed around postop bone and soft tissue maintenance, led us to this 2 month post op
The approach I would have used before adopting digital workflows would have been a fixture level, open tray polyvinyl impression. I would have placed the implant analog, made a soft tissue model and sectioned the die myself prior to sending it to a lab for an abutment (before my implant education, I would have done a closed tray impression using a stock abutment and a snap cap). When it came back I would often be disappointed by the contours of the abutment, the height of the margin relative to the tissue, and then the contours and contacts of the restoration. In this case, the digital workflow used was to image the Atlantis scanbodies and send the case via CEREC Connect to Atlantis, where they design custom abutments and send me their design (based on my preferences of contour, margin placement, etc.) to approve prior to fabrication.
Once approved, Atlantis will send a Core file, which you can load into the CEREC chairside software and produce the crowns over their abutment designs in the 3 days it usually takes them to manufacture and deliver the custom abutments. This is a far less frustrating process than dialing in the fit of the crowns chairside. In fact, the first time the crowns I produced touched the custom abutments was in the mouth; I was so confident they would fit, it didn't even occur to me to test the crown to abutment fit before seeing the patient! Here are the custom abutments immediately after seating them to spec
And finally, here are the restorations on recall
All of these technologies and techniques are valuable on their own, but combining them helps us address the patient in a more nuanced yet predictable way. It has been such a great journey adopting these work flows into my practice and seeing what they've contributed to consistent clinical success, improved patient experiences, and personal gratification. I am looking forward to what's next, and sharing those with this terrific community!
We recently undertook the challenge of completing a 28 crown full mouth rehab case with strict orders of getting it done in 5 visits only due to travel and time constraints.
More on that later but today we did visit #4 and it took 2 hours and 40 minutes.
4 crowns. 2 ovens. 1 mill. 1 scanner. 160 minutes.
Sure a second mill would be great, but using the Speedfire and Programmat simultaneously can really boost efficiency. There are many ways to treat a quadrant in one visit and here is the workflow we chose today.
Numbed patient at 1:30pm. Teeth #'s 28, 29, 30 and 31 were prepped for emax by 2:30pm. Preps scanned, designed #28 and we began milling #28 which took 5.5 minutes. While 28 was milling we started designing the others.
Milled #30 for 8.5 minutes.
#28 & #30 placed in the Speedfire for 26 minutes.
Milled #29 for 5.5 minutes and #31 for 8.5 minutes.
Placed #29 and #31 in the Programmat for 16 minutes, checked contact and occlusion and bonded #28 & #30. As clean up was finished, #29 & #31 were ready. #29 & 31 were checked, bonded and final checks completed.
The patient walked out at 4:10pm.
Sure we could have done it with just one oven but it was a lot less stressful utilizing both simultaneously.
So if you dont have a Speedfire, get one! Dont have a Programmat, get one!
Its a lot cheaper to add an oven than a mill.
We all have these patients in our practices. They present with lower anteriors that are stable, but have moderate-severe bone loss and some mobility. Options for treatment might include electively extracting the teeth and placing a tooth-supported fixed bridge, an implant-supported fixed bridge, or simply watching the teeth until something happens. My philosophy is conserative for cases like these, so we watched the area for about 2 years, and the day finally came where my patient was experiencing pain due to resorption on #25.
We discussed electively removing #23-26 and placing 2 implants for a 4-unit bridge, but the patient was concerned about finances. A 3-unit tooth-supported bridge was out of the question since the adjacent teeth are periodontally involved. Because of the CEREC, we were able to offer another treatment option --- the Maryland bridge.
I decided to do a single-wing Maryland bridge. Due to the severe crowding, I prepared the buccal surface of #24 (instead of the lingual). I used Biocopy (imaged the pre-existing tooth prior to extraction) as the design technique. The area was restored with Emax LT A3.5 (size 16 block). I used the Meisinger kit to add surface characterization after the restoration was milled, and I used a fair amount of staining to mimic the adjacent teeth. The milling took about about 20 minutes, and the firing time was 24 minutes. The total time for the whole case (extraction + restoration) took less than 2 hours.
These cases are very predictable, and it’s a great service for our patients who cannot afford the alternative treatment plan.
Here is the pre-operative clinical view of the teeth 1 month prior to treatment.
The pre-operative radiograph clearly shows the resorption which was the source of the patient's discomfort.
The biocopy image was taken to maintain the original position of the tooth
The restoration was designed to about 75% completion. Using the Form Remove tool, I created a notch where the CEJ was to be. The remaining effects (developing the exposed rooth appearance) were created post-milling using the Meisinger kit.
Since the tooth had class 2 mobility, the extraction was straightforward and took less than 3 minutes.
Here is 1 week post-op final image of the bonded Maryland bridge.
The final radiograph
Just completed my first Azento case today. This is probably the easiest guided surgery workflow I've ever used.
I uploaded the cerec scan through the sirona connect portal and the dicom through the www.orderdigitalsolutions.com website.
Within a few days I had the planned surgery available for viewing. The best part of this was that the portal is accessible from my iPhone. I was able to approve the case design from my phone while being away from the office/computer/etc.
This case from anesthesia to final radiograph was under 25 min.
The design of the guide was so convenient with a lingual access window. This was great for working in the area of #30.
This keyless system is a breeze. But better than that, having a streamlined surgical kit makes setting up the operatory and passing the correct drills so easy for my assistant. Just compare the size of the Azento kit versus the standard guided Astra EV kit.
Finally, I was really impressed with how easy it was to line up the implant timing to replicate the digital plan. The custom healer matched the profile of the tissue perfectly.
The digital workflow just keeps getting better and better!
I get asked this question a lot from prospective CEREC owners and new user, the reason is that many of us have seen bad CEREC margins over the years. My answer is that this is no different than good and bad lab crowns. If I prep appropriately and take a good impression, likely the lab or my CEREC will be able to produce a good result. The opposite will be true if I don't.
The reason this site, basic or level 1 training, and level 2 training is so important for all users is that it not only teaches you to use the software, but how to prep, design and bond for success. It really doesn't take any more effort to get a great fitting restoration instead of a bad one, but it does take education.
The Dentist that did the CEREC crown on the left used a similar machine as mine, and took about the same amount of time to make his crown as I did for the one on the right. The difference is that he simply didn't know what the machine needed to give him a great result. If you're new to CEREC or not getting great results, get the education you need from cdocs and the results will be there. Sorry for the commercial, but I really believe strongly in the education available here.
I received a sample of Ivoclar Vivadent's Tetric CAD. This was a case that I thought would be more of an onlay and my mind was dead set on using the block. In my humble opinion this block is perfect for inlays and onlays. The tooth's condition dedicated my prep and with the presence of distal decay that wasn't apparent on the radiograph and with the small buccal breakdown, I changed gears and went with a crownlay prep. In the past, I would typically use IPS e.max HT or MT for these crownlay indications.
Tetric CAD is in the category of hybrid ceramics. It has great edge stability during milling, polishes easily and doesn't have to be fired. With a flexural strength of 272 MPa, it is higher than the other hybrids. I bonded this restoration with Ivoclar Vivadent's Variolink Esthetic DC Warm cement under rubber dam isolation. I have attached a CEREC Materials spreadsheet that I posted earlier this month for those that would like to see the different materials and their properties and indications.
This appointment was less than an hour from start to finish. Polished only. Despite the fact that the value is a bit high occlusally, it still blends beautifully around the margins.
A few months back, I was in the Demystifying Occlusion seminar with Frank Spear and he talked about the prep and pray method for doing posterior crown. It got me thinking about how I used to restore anterior implants via the "Pour up and pray method." My "pour up and pray method" was removing the healing cap, placing the impression coping as fast as possible, squirting impression material into the socket and praying the lab technician could replicate the soft tissue and the emergence profile.
Cerec and its workflow make it so predictable and take all the challenge and guesswork out of anterior implant restoration.
Step 1: scan the day of implant surgery and make a custom healing abutment with enamic.
Step 2: rescan a few months out. used bio reference to copy #9. Fabricated custom incoris zirc abutment (infiltrated) with emax lt c2 for the final crown in extra fine mode.
The last few photos were before cementation yesterday, so it does look a little bit long, but the incisal length is perfect after cementation.
Quick thoughts on the zirconia abutments: 1) mill so smoothly 2) you can also buy them in single packs instead of buying packs of 5
There are situations where the spacing for implant therapy is not ideal one way or the other. With the CEREC-Galileos integration we have the ability to create 2 different plans and decide which one works better.
What do you guys think, 2 or 3?
Late night CERECing thoughts...
It's very humbling to look back on cases when I started using CEREC 12 years ago. I was so happy to take a crown straight out of the mill and put it in the patients mouth. I had no idea what I was looking for when I looked at a tooth, other than if the color was right (which really meant was it close but not perfect). Today, I look at teeth in an entirely different way. I love to see the color patterns, the anatomy, the contouring and the light reflections. I am able to see this now because I posted cases and other doctors were willing to show me how to improve. I was also willing to accept those answers. That is what I love about this forum. We are all here to grow.
So what do I see in a case like this...
Anatomy of a youthful tooth: sharp line angles, prominent central lobe and contouring at the gingival embrasures on the mesial and distal. This is contouring that is done post mill.
Fun color patterns: the white bands at the gingival 1/3, the blue translucency and the white framing along the incisal edge.
Reflections: Do my reflections mirror each other? If so, then my anatomy is similar. If not, I need to re-contour to get them to match.
and the final...
Don't you just love that we have this capability in our office? So.dang.cool.