Doc I don’t really smile....
Patient presented wanting his smile fixed. Concerned with the laterals and #5. After 5 years of seeing him finally allowed me to do 7 first. Once he saw it signed up to do 5 and 10 in 2 weeks. When we finished this week he said now he can stop smiling on just one side. 😂 Vita Triluxe 7,10. Empress CAD 5. It is very rewarding to be able to change a patient’s esteem with their smile.
Hope everyone has a great weekend.
Beautiful! I love making what's there more beautiful.... love the 10 unit cases for pop, don't get me wrong. But this is a great improvement and better assessability for the patient to help them look better, and YOU figuring out how to execute it. Nice!
David, it really comes down to what you get comfortable with. I think you could get a great result with several different materials. However, my thought process goes in this manner:
1. Warm looking tooth or bright tooth. Also can include age of patient (older the tooth less brightness they have). If I’m going warm I will stay in the VITA realm. If it is bright I’m leaning towards Empress. Only way I’ll do EMax in the anterior is if I’m worried about strength or if I’m doing multiple teeth in which I’ll use MT and if I’m matching an existing PFM I’ll use LT. I tend to shy away from HT in the anterior as I feel it greys out.
2. Shade gradient. Some teeth have it and some are very monochromatic. For warm teeth If the gradient is there I use Triluxe for VITA if not Mark2. If it is bright teeth with gradient Empress Multi if not Empress CAD.
I’m mainly staying in the EMax family and stick with HT or LT. If I have a premolar and feel comfortable not needing strength I’ll use Empress CAD or multi using the decision formula I stated above.
Hope this helps
So easy answer is that my assistants do all of this 😂 however, I can tell you how what they look for and if I need to I can elaborate more, I will on Monday.
So they will try and pick a block that best matches the lighter areas of the tooth or the broadest area if that makes sense. They can always apply stains to tone a tooth down but almost impossible to lighten it. Don’t be scared to mix stains to get different color schemes and just keep them on your palate covered so they don’t dry out. In general, I think dentists stress too much on the color when deciding. I believe that this is the order you should focus when trying to match these:
1. Value. Most important... essentially the brightness level
2. Contour and surface texture. Pay attention to line angles and how light reflects of your crown and adjacent teeth. Take tons of photos. Even when trying in. What you see might look completely different when taking a photo. Sometimes we’ll put these up on screen if we want patient involved. But get a good dslr with dual point flash setup. Ring flash is horrible for anterior evaluations.
3. Chroma. At this point if you matched first two have way more wiggle room here.
If you nail value and the shape and texture patient will not pick up that your chroma is off. Since my assistants have been able to train their eyes to pick a block with that value I can focus on contouring/polishing which we do chairside. They are getting much better at this now. So most of time I’ll just look and they are 95% there.
After this they will take the crown back to lab and look at a photo on a monitor in the lab for a guide. We fire on P4 (Empress cycle) and use empress stains and glazes. Use honeycomb tray with the thinner metal pins with a little putty.
After that comes out we can refire to correct if need be or just begin to polish to match surface texture. Sometimes we’ll polish most of glaze off if it looks too shiny. Natural teeth are not shiny. Saliva gives it that appearance.
A lot of this is practice and trial and error. You learn a ton in the Level 4 workshop in Scottsdale and in Charlotte. This is where I started getting more comfortable with anteriors. In addition, if you have a great relationship with your ceramist they may be willing to come to your office and share some tricks with you. I have done this in the past multiple times for him to show my assistants. He also has a course he teaches locally and you can PM me if interested. Let me know if you have any other questions. Hope this helps.
Just to give you an idea. This was straight out of mill and then contoured. We take this photo so they can evaluate how much they need to change the cervical. Even though it’s a triluxe the natural teeth had more of an intense gradient they had to match.
also shows you that you can match and save most cases because value was correctly matched
It really depends on each case. If we are in hygiene or new patient exam and have decided we want to do an anterior case, I'll have my assistant come and take a quick look. They are getting an idea for block selection and how many times they think they'll may have to fire it. Normally I'd say for 1 anterior we will schedule between 2-3 hours. Always ask patient if they are ok with that amount of time, very few will say no.
Now, what benefits us as CEREC users is we can accomplish multiple procedures in one visit. So with this case in particular, patient wanted to go ahead and do #5. Our time did not change that much since you have the option to just polish and bond #5. So we start with prep of 10, get that milling. My assistant takes over from there and we manage the time by either another assistant helping me out while the first is contouring, staining and glazing, or while 10 is milling, I'm prepping 5. Just maximizing the time of that appointment is where to me the actual length of the appointment doesn't mean so much.
Always ask the patient if they want to do more, you never know.