Blog

I want to thank Don Bell, the Director of Marketing CAD/CAM for Ivoclar Vivadent for his strong presence on the boards at cerecdoctors.com.  I was reading the site today and he posted some great information about Multilink.  He touched on the fact that people in general are not big fans of reading directions.  We generally feel that we'll figure it out.  I hate to admit it, but I've done this from time to time too.  This can be a huge mistake, especially when dealing with adhesive dentistry.  I find that the adhesive part of the CEREC process is that part that most people have questions on from the start.  It is so much easier to just cement a crown, we all know that.  It is imperative to know your bonding agent and how to properly use it.  Today Don talked about some studies they did on Multilink.  They had some questions about how long was long enough to scrub the dentin and enamel with the A & B mixture.  The correct amount of time to scrub the dentin with the mix of A & B is 20 seconds.  Look at what happens to bond strengths when you don't follow directions:

It is so important to follow manufacturers instructions.  The adhesive step is probably the most important step in the long term success of the restorations that we place.  Please take the time to learn how to use them correctly!

*Here is a great blog from one of our Mentors Dr. Darin O'Bryan.  He posted this on the Spear Education site and we thought it would be a great blog for the CEREC guys as well.

If you asked most of your patients if money was no object would they fix their teeth, the vast majority of them would say yes.  We all have patients in our practice that need our services and want to have the best that dentistry can do for them.  How many times have you talked to a patient and they realize they have needs that should be addressed but financially they just can not afford the multitude of crown and bridge that are necessary?  With the current economic trend more people are being frugal with their discretionary income.  I don't know about you but I don't have a ton of patients with a bunch of cash set aside to fix their teeth.  How can we make it possible for them to have the quality care they want and make it feasible financially?

For the patient that wants the best but can not afford complete restorative care at this time it is necessary stage their therapy over time.  Long term provisionals with composite are an ideal way to accomplish this objective. 

Once the patients restorative needs are determined an ideal wax up is created.  The wax up is then duplicated in stone and a vacuform matrix is created.  The matrix is trimmed to the gingival margin to make easier clean up.  Caries removal is done on teeth with disease.  Restorations can either be left or removed depending on their condition.  For metal crowns retention grooves can be cut into their surface.  Crowns with a porcelain surface can be abraded and then conditioned to bond to the resin. 

Once this is done the patient is isolated and the proper bonding protocol followed for the underlying structure.  The matrix is then filled with composite and seated on the arch.  The gross excess is trimmed away and the whole thing is cured. The teeth are then sectioned if so desired with fine finishing burs, cera-saws and finishing strips.  The same is then done for the opposing arch if needed.  

There are a number of benefits to staging a patients therapy in this way.  It allows the patient to have the crown and bridge work done over the course of years if necessary.  If they are an insurance mind set patient now their insurance will cover the crowns one or two a year.  It is also a great way for the patient to test drive their new occlusion and pathways of function.  If the patient has GERD's or acid reflux it is also a way to verify control of the condition before moving on to more costly procedures.

Now biocopy is your friend.  One, two or the entire thing can be duplicated with biocopy.  If this is a patient that can only afford or wants to only do 1-2 crowns a year then you can leave the others until such time as their insurance rolls or the patient decides to do a few more crowns. 

The combination of the composite mock up and CEREC is a powerful tool that allows the delivery of ideal dentistry over time with amazing results.

Providing your patient visual access to their dental problems is so helpful in getting them to realize just what the problem is and the steps that need to be taken to correct it. Many problems arise slowly over a long period of time. In the absence of pain, many patients may not even realize that a problem exists in the first place. We need to walk a fine line between being perceived as over diagnosing and suggesting unnecessary treatment. This problem can many times be solved by showing the patient the problem so they can be a part of the diagnostic process.

Intra oral camera’s served this purpose for many years. The quality of the image was poor but the point was made. Once we realized the power of this tool it was obvious that this type of diagnosis helped us in many ways. Next came the digital camera. With proper training we are able to get superb intraoral photos. Showing them enlarged on a monitor or Ipad is a great way to get your point across and open up a discussion.

There is another way to approach this subject as well. It is one which is simple, in direct view of the patient and needed for the current treatment. I am referring to the virtual models.  I will commonly extend my models to capture any broken teeth, open contacts or poorly adapted fillings. When the patient is watching me design, it is simple to show them these areas. Either on the working model or the counter and begin a discussion. It’s all about education. Showing a patient what their problem is and allowing them to understand it will leads to greater patient acceptance.  Since you already have the model on the screen, Why not use it to its fullest? If a picture is worth a thousand words, a virtual model must be worth a lot more.

In this screen shot, this patient was advised to treat the problem on 19 at the same time as the treatment was rendered on 18. She refused until I pointed it out to her on the screen. We sent 18 to the mill and went ahead and prepped 19. Not so efficient but it got done. Use you CEREC to its fullest!

I find myself spending a few extra seconds at the Mill Preview screen these days. Setting yourself up here will save time later, and being more accurate with your sprue placement will make your perfect contacts remain that way. It is really simple, using good magnification, to remove the sprue completely and accurately from the contact area, but why even have to do that if you can be more precise in its position in the first place.

At the Mill Preview screen, it helps to go to Display Objects and turn on the model of the arch where the restoration is located. This will show you exactly where the contact is located. You can then position the sprue where it will not interfere. Just a little tip to make your CEREC life a bit easier.

A couple of years ago my sons, who are big basketball fans, tried to talk me into buying season tickets. I was reluctant at first—I had always enjoyed going to the occasional game or watching with the boys when there was a game on TV, but I wasn’t sure I wanted to make a commitment like that. Then they pointed out that it would mean us spending more quality time together on a regular basis, and I was sold. That’s how I ended up occupying a near-courtside seat. And that’s how my level of engagement with the sport of basketball changed dramatically.

It’s incredible how different the game seems when you are practically right in the action, witnessing the size and speed of the players just inches from your nose. And then there is the feeling of being at the forefront of a group of rabid screaming fans. You can feel the waves of emotion behind and all around you, and you can’t help being caught up in it all. It’s a level of intensity that just can’t be matched by watching on TV, or even from farther back in the building. Just by being there, up close and personal, I have become so much more emotionally invested in the game.

I think the same phenomenon applies to CEREC owners. Anyone who buys a CEREC is by definition, well-invested in it. We are talking about a significant purchase, after all. But there are CEREC dentists who make the purchase and who do the “due diligence” training—an introductory course or two—and then they just take it from there themselves. They’re fans, but their level of engagement is still somewhat removed.

And then there are the ones who really get in the game. They want to get up close and in the action. They attend advanced courses where they can see firsthand how the masters do it and get hands-on experience duplicating their techniques. They stay on top of new developments through online video education. And perhaps most importantly, they get together with other CEREC raving fans at events like CEREC 27 & a half.

As a CEREC owner, you owe it to yourself to be there among the “season ticket holders”—up front, courtside, and in the game. Trust me, just the experience of being there will transform your level of engagement.

Imtiaz Manji
CEO, Spear and Scottsdale Center for Dentistry

In his current role as CEO of Spear and Scottsdale Center for Dentistry, Imtiaz reaches thousands of dentists each year with his speaking engagements, online CE, published articles and popular blog, all the while providing the strategic vision and corporate leadership behind the industry’s premiere destination education center. In addition, Imtiaz lends his skills and passion to the Open Wide Foundation, whose mission is to bring quality dental care to impoverished communities around the world.

Imtiaz will be a keynote speaker at CEREC 27 & a half discussing “The True Value of Dentistry.”

I'm sitting in the auditorium of Scottsdale Center for Dentistry and I'm just very energized. Those who know me are thinking, "what else is new!"  

The reason that I'm so energized is the fantastic meeting being given by Sameer Puri, Armen Mirzayan and Mike Skramstad. They are doing a weekend of lectures for our esteemed cerecdoctors.com Mentor Group on how to properly document cases and create beautiful presentations. I'm sitting toward the back of the room and decided to take a photo of the meeting in action.

This is just such a great lecture given to the mentors to teach them the tools to go out and put on presentations like the guys teaching it. We learned Camtasia, Dropbox, iMovie and Handbrake. They show how to record CEREC procedures off the CEREC machine and produce them with audio. They show how to edit videos and photos in iMovie. They not only showed everyone how to use these different programs but sent everyone away with the presentation so everyone has a tutorial to allow them to practice and create these presentations in both Keynote and PowerPoint.

I remember a few years back when Sam told me about his plans for the mentors and all the content he wanted to provide to them. This year he has gone above and beyond all he discussed with me. I'm sure that this course will be given again. If you are a mentor and didn't make the course this time, don't miss the next one. If you are not a mentor, contact Shayna Phipps at Scottsdale Center and get some info about it. The only thing better than the meeting is being with 100 friends here at the center taking the class with me.

I’m sitting in the airport on my way home thinking about what has happened over the past few days in Las Vegas at the Townie meeting. A few things stand out.

The presentations I went to were really good, great quality across the board, great responses from the audiences. Many of the GALILEOS and CEREC-based presentations were given by individuals who will be presenting at CEREC 27 & a Half, August 16-18 in Las Vegas. This material is inspiring and thought-provoking; I can’t wait to see what these presenters bring to the big event. There are a lot of developments with the software and the materials that will make the life of the CEREC dentist easier, and the treatment we deliver to our patients better. These people are pushing the CEREC boundaries, and this August they will share much of what they have figured out.

The other thing that stands out is the people of the cerecdoctors.com Mentor Group. These are individuals who are truly special – always willing to answer questions, spend the time spreading the advantages of CEREC and cerecdoctors.com even when they didn’t have, they were in Vegas after all, vacation time. Many I already knew, many I met for the first time, but it was like we were longtime friends. I guess it shouldn’t have surprised me since I have interacted with many of them on a regular basis through the website. The mentors are a fantastic group of individuals, always there to support their fellow dentist, to help them advance and improve their dentistry.

Remember back to the last time you had a tire replaced on your car. The mechanic used a torque wrench to tighten down the lug nuts to the proper specifications. Then he gave you specific instructions to return after driving 25 miles to have the lug nuts re-torqued. Did you ever wonder why? Well, there is a real reason behind this and it is called “The Settling Effect.”

As CEREC dentists we have honed our skills to such a high level that the placement visit has been shortened considerably. I find that when placing my favorite restoration (the screw-retained e.max crown), I have minimal adjustments and minimal chair time. Well, that might be something that needs to be reconsidered. In an article published in The Journal of Oral Implantology by Sheldon Winkler, D.D.S. et al. The Settling Effect is discussed and offers a compelling reason for implant screws loosening. It is something we all need to know about and take steps to counter.

So, we all know that we need to torque our implant screws to the manufacturer’s recommendation. That is called pre-loading the screw. Torquing actually elongates the screw and pulls the abutment and implant together, and essentially acts like a clamp. Fighting this pre-load is occlusal forces or joint separating forces. So we have this fight going on between the implant and abutment at all times. The pre-load generally wins this battle and the restoration is a success.

There is a phenomenon which can tip the tides against us. As finely machined as implants and their components are, on a microscopic level there is a roughness. As the components mate and the screw elongates to pull them together. This roughness prevents full seating of the abutment to the implant on a microscopic level. Soon after torquing of the screw, the rough areas can collapse, making the fit between the implant and the abutment more intimate. This is a huge concept to understand. If the implant and abutment slide together more over time, the torqued screw is no longer torqued to the proper specifications. This article found that the torquing or pre-load can be decreased by 2 percent to 10 percent. This is The Settling Effect.

Add to that the other main reasons for implant screw loosening like excessive or misplaced occlusal forces or inadequate design of the restoration, and you are providing a force which will further increase the micro-seating of the abutment and thus a further loss of the pre-load. Now you have a screw which is functioning without the proper torque, and it loosens. Leave that screw in function for a while before the patient is aware of it and you can have a failure of the screw itself. I will also add my own thought, and that is while e.max is a wonderful material, it is unforgiving to the bite and marks poorly with articulating paper. This can further affect the preload and lead to a loose or failed screw.

Well, what is the answer? It's really simple. The article found that much of the pre-load is lost in the first 10 minutes after the initial torquing. So, just wait 10 minutes and re-torque the screw. It really is that easy. Also, check and recheck your occlusion and relieve any interferences. Design your restoration with the proper anatomy and do not over-build the occlusal table in a buccal lingual direction. That should solve the majority of loose screw problems.

This phenomenon proved itself to me on a larger scale a few years ago. I had a tire replaced before a vacation and the mechanic told me to come back after driving 25 miles to re-torque the lug nuts. I told him that I was traveling and that wasn't possible. He said that I must retighten the lugs, and was insistent. I stopped after about 75 miles and grabbed my lug wrench. I was amazed. Every lug nut was loose and not just a little. The Settling Effect is real; it's dangerous on a large scale and inconvenient on a small scale. Slow down, do a hygiene check, talk more or grab a coffee, but re-torque that screw in 10 minutes.

The article can be read here.

Here’s another way to help organize and keep track of multiple files of the same tooth on the same patient.

I recently had the privilege to be part of the cerecdoctors.com mentor field trip to Bicon Implants. The trip included an implant surgical and prosthetic course held at their headquarters, a facility second to none.

The first thing that caught my attention was the person in the front of the room. Why was my Uncle Bill standing in front of the class? The same mannerisms and that Irish smile jumped out at me. But it was not Uncle Bill, or as his nephews and nieces referred to him, “Sweet, lovable, Old, Bill - SLOB.” A nickname that he cherished; it always brought a smile to his face. And as we got older a quick and witty sarcastic response would just as quickly be returned that made the room erupt in laughter. If you dish it out, you’ve got to take it was how he lived. He was a man stuck in his ways and had the experience to prove his point.

After shaking my head I realized it wasn’t my Uncle Bill, but Dr. Vin Morgan, the head of Bicon. He started by telling us the story of Bicon, how they have met opposition in the past and still face it from companies with larger marketing budgets. These companies unwilling to accept the position and products of Bicon – a company that hasn’t changed the basic design of its implant since it started in 1985 – while these other companies make a normal practice of switching this and changing that on a regular basis.

The hard facts of implant dentistry are not hard facts any more, and Vin Morgan helped to open the eyes of the mentors in the room. He said that they say what they say and you can accept it and bring it into your office, or you can stay set in your ways and at least have a good dinner at the end of the day and go home.

As the day went on I started to see how the advantages of their system worked. The advantages of their surgical protocol definitely raised eyebrows all around me. Case after case of fantastic soft tissue. Case after case of bone growth around the implants, even those that have significant discrepancy with the crown-to-root ratio. In fact, as they have matured as a company, they have gotten away from implant lengths that we would consider the norm. All of their long implants have been discontinued since the shorter implants have a better response from the host. There were implants placed in sites I would never had attempted to try and these implants did more than just stay, they grew bone.

As Rich Rosenblatt said in his blog, there are a lot of similarities with the journey of Bicon and CEREC. Just as I find Sirona a great company to work with as a partner in my practice, I see Bicon being another great partner.

As I finished my dinner at the close of the course, surrounded by some great CEREC friends, we asked Dr. Morgan, “So how was the dinner?” I tried to stir the pot and say, “The first course was good, but I expected some good Irish food!”

He said, “Well if that was the case, then you pick up the tab.”

Uncle Bill, are you in there?

We all left with smiles after a great weekend and Dr. Morgan shared some words that mean a lot to me:

“The doors to this house are always open for you; we are here to help you however we can.”