Value-able Lesson
Just thought I would present a case where I had screwed up(I have plenty) earlier on in my CEREC career and I finally had a chance to make it right. Ironically, I am speaking to our dental students next month on Iatrogenic dentistry, so I have been putting the presentation together, and this case will be in it. This patient presented in early 2013 for a crown on #8 due to a "dark tooth" after some trauma he had several years earlier. He also had some old bonding on 9 but he wanted that left alone as he had it replaced multiple times before and it was now stable. I was just starting to play around with anteriors with CEREC, and obviously I had a lot to learn. I took a quick shade, decided A-2 seemed to match, and we went forward with an Empress Multi block in A-2. I still love Empress Multi for anteriors, but when I first started using it I was almost trying to force fit it into situations where maybe it wasn't appropriate. At the time, the patient was very happy as his tooth had been pretty dark and so he was happy just to have a significant change. Once I heard he was happy, I couldn't bond it in fast enough! When I saw him for a follow-up, he was still happy, but I could tell that I clearly had missed...I discussed with him trying to replace it but he didn't feel there was any reason to.
Fast forward to this week, and he is unfortunately getting divorced, which is causing him to re-assess everything. He mentioned that in pictures he noticed his tooth looked dark, and he was wondering if I would still be willing and able to replace the crown. Of course, considering I always hated his crown more than he did, I was happy to oblige...these patients are our advertisements to the world, so I would much rather have him looking as good as possible. The lessons learned here and in Scottsdale gave me a totally different way to assess the case and think about the final restoration, especially with regards to material choice and focusing on the value, texture, etc. So, we removed his existing crown, refined the preparation, and fabricated a new crown in e.max A-1 MT and bonded it in place using VarioLink Esthetic Light:
While it isn't perfect, and looking at the pictures I may need to adjust the length slightly when he comes in for a follow-up, this is obviously a much more acceptable result...hopefully this helps his confidence as he moves into the next phase of his life. I was only out a little time and the cost of materials, which is a small price to pay to be able to sleep at night knowing that I have done right by my patient. Now if I could get him to let me replace that bonding...
The real takeaway is to focus on value and texture, especially when it comes to anteriors...if you haven't taken Level 4, it is an amazing course that can really help out with these aspects. And if something isn't up to your standards, don't be afraid to make it right. We have such an advantage in being able to control the cost and the outcomes we obtain, so take advantage of it! Your patients will appreciate it, your team will have more respect for you, and you will feel better about your practice as well.
Nice Case Ponz!
I agree the MT blocks have really filled a need with eMax in the anterior. Especially in combination with the multiple shades available in the Variolink Esthetic Line.
Great post, thanks for sharing!
You said it isn't perfect....After the second go around, if you had to do it a third....What would you try to do differently?
I think I left it a bit too long incisally, and I may have rounded the disto-incisal line angle a little too much when compared to 9, although I may be able to correct that if/when I shorten it. I am way happier with my mesial and distal line angles and the texture. Those are the real things that stand out to me, but I certainly welcome any other thoughts!
Great documentation and it's cool to see your evolution. We all get better at this over time.
awesome job. The color is clearly different... but the shape is what truly makes it better. What did the prep look like...do you have a pic? It's still just slightly low in value (but that is being extremely picky)
Nice case Ponzio. Shape and contours much better. I am like mike and being extremely picky about the value being low. I wonder what a mark 2 would have looked like there. Also stump shade would be interesting to see.
Thanks...I was definitely much happier with the contours(thanks to your tips Mike). I see what you are saying about being slightly lower in value as well. I don’t think I snapped a pic of the prep(other than the scan) but it wasn’t horribly dark...that being said, maybe I should have blocked it out anyways? I will see how clear it is on the Omni scan Monday and upload that just for discussion sake.
Here is the screenshot of the prep-fairly traditional prep but I was able to preserve the cingulum...as you can kind of see, it wasn't overly dark, but maybe I should have blocked it out anyways to help with the final value:
My design shows the slight excess in length that we see in the final as well:
