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Gingivectomy and restoration on tooth #8 performed by Joshua Weintraub, DDS

This case demonstrates how Solea can be used to ablate both hard and soft tissue with no anesthesia, no bleeding, and fast healing.

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Case Summary: A 67-year-old male, who has been a long-time patient of the practice, presented for his follow-up appointment. The oral evaluation revealed the recurrent subgingival decay on tooth #8 DFL (Class III/V combination) under an old composite restoration. The clinical objective was to restore #8 while performing a gingivectomy to access subgingival decay.  Total procedure time from start to finish was less than 30 minutes.

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Technique Used: No topical anesthetic or injectable anesthetic were used for this procedure. To start, a gingivectomy was performed to enable removal of the subgingival decay and achieve a clean margin for proper restoration. Next, the old composite and recurrent decay were removed with Solea. The removal of gingiva was performed using the 1 mm spot size with cutting speed between 30-50% with 20% mist. This took less than a minute and did not require anesthetic. The 1 mm spot size with cutting speed between 30-60% with 100% mist was used for removing the decay and old composite. The enamel was beveled with a diamond bur. Finally, the tooth was restored. The entire procedure was completed blood-free (the slight redness on the ‘Restored’ photo was caused by the finishing bur at the gingival margin).

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Solea Advantage:

  • The treatment was completed without anesthetic, was blood-free, and completed in less time compared to traditional approach.
  • The soft tissue healed extremely rapidly due to the minimally invasive precision of Solea.
  • The patient experience was enhanced due to not being injected with anesthesia, avoiding post-operative pain, and a shorter appointment time.

Results: With other instruments, the patient would require an injection in the maxillary anterior region – one of the most uncomfortable places to receive an injection, regardless of dentist’s skill level. This procedure would have likely taken much longer to complete with traditional instruments and techniques, compared to under 30 minutes with Solea. Time savings were achieved without the need to inject the patient and then wait for the patient to become numb. In addition, rapid and easy management of the soft tissue saved time. The patient was excited to avoid the shot, possible post-op pain, and hours of numbness after the appointment.


Deep Troughing for Margin Isolation #5 performed by Timothy Anderson, DDS

This case demonstrates how Solea easily enables virtually blood-free soft tissue procedures without anesthesia resulting in better digital impressions for CEREC restorations.

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Case Summary: This patient of record presented to the practice with a failing restoration and recurrent decay on tooth #5. The patient stated that he really disliked being numb and wanted to avoid the injection. As can be seen radiographically and in the pre-op photo, the distal restoration was significantly subgingival. No anesthetic was used during the treatment.

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Technique Used: The existing composite and decay were removed using Solea. The tooth was prepared for an Emax crown with the Meisinger CEREC Doctors prep kit. Solea was then used to remove adequate tissue for imagining in a clean, bloodless field. No cord was needed and the troughing took less than 15 seconds. The final scan was taken with the CEREC Omnicam. The restoration was designed with CEREC 4.6 Chairside software. The crown was milled, stained and glazed. Crown was then bonded with Variolink Esthetic.

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Solea Advantage:

  • Solea enabled the dentist to perform this treatment anesthesia-free.
  • With Solea, the procedure was completed in less than 15 seconds compared to several minutes traditionally.
  • Solea’s ability to precisely and virtually blood-free trough gingiva allowed for an effortless perfect scan.
  • The dentist delivered an impeccable patient experience including not administering anesthetic, a shorter appointment time, and increased patient comfort post operatively.

Results: The key to a successful CEREC same-day restoration is the ability to have smooth clear margins with separation at the time of scanning.  Traditional methods, like retraction cord in a single or two-cord technique, increase procedure time and don’t always deliver predictable outcomes. Solea’s unparalleled precision enabled the dentist to sculpt the tissue for restorative excellence and immediately proceed with definitive restoration. Thus, the Solea and CEREC combination allows for the simplified same day dentistry.


Crown Lengthening (Clinical) #14 performed by Timothy Anderson, DDS

 This case highlights Solea’s exceptionally clean and precise cutting of soft and osseous tissue that enhances the CEREC’s same day dentistry workflow. 

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Case Summary: A 62-year-old male patient presented to the practice with very deep decay to the level of the alveolar crest. Tooth #14 required clinical crown lengthening to restore with a crown. With Solea, performing the surgery and placing the definitive restoration on the same day was possible.

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Technique Used: To start, the existing amalgam was removed with a carbide bur. Caries was then removed utilizing Solea. A full coverage crown preparation was completed using Meisinger CEREC Doctors prep kit and an electric handpiece, and some minor troughing was performed to expose margins for a final scan without the need for retraction cord. An Emax crown was designed utilizing the CEREC 4.6 Chairside software and fabricated. Crown lengthening was performed during milling and glazing. A minimally invasive flap was reflected with a periosteal elevator. There was minimal tooth structure coronal to osseous crest on the distal and distal-lingual surfaces. Solea was used to remove and sculpt osseous tissue until there was 2 mm of tooth structure coronal to the bone. Positive bony architecture was maintained. Solea provides unsurpassed precision and clear visualization allowing removal of bone without iatrogenic damage. The final restoration was inserted with SpeedCem Plus self-adhesive resin cement. A single 4-0 chromic gut suture was placed.

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Solea Advantage:

  • Solea’s remarkable precision and improved visualization allowed for removal of osseous tissue without iatrogenic damage.
  • Solea enabled complete control of soft and osseous tissue resulting in a very fast and minimally invasive surgical procedure (completed in under 10 minutes with only minimal bleeding).
  • The Solea and CEREC combination allowed the dentist to finish the entire treatment, crown lengthening and the crown itself in the same visit – a true “crown in a day”.
  • The dentist was able to perform this procedure in-house rather than refer it out.
  • The patient was thrilled not only with the esthetic outcome but the speed, comfort, and efficiency, at which the treatment was completed in one visit.
10 Oct 2019

Posted by Thomas Monahan on October 10th, 2019 at 09:35 am
View Comments (10)


Just wanted to share a 3 year recall on one of our earlier anterior cases. Patient finally allowed me to replace an old existing PFM. What was interesting about this case is the spacing was not the same and we informed the patient of the challenge. She did not want to pursue ortho, so we had to mask the discrepancy with contouring. Overall, I think it turned out well and the material has held up great over the last 3 years. Again, if you are not doing anteriors, get yourself to Level 4 in Scottsdale or Charlotte to get some training.

This was Vita Triluxe done with 1 fire.

Initial:

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Immediate Delivery:

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3 year Recall:

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Tom

 

06 Sep 2019

Hey All,

It's been a while since I've posted anything.  Long summer and trying to get back at it.  I think for all of us on here, we are thankful for technology and the constant evolution of materials and digital dentistry.  

This case I'm sharing is something that all of us see each day.  How I approach this today is different than I would have approached this pre SpeedFire and pre-Katana.  I simply love the fit of Zirconia and the anatomy right out of the mill.  I can be much more conservative with my margin preprations and edge stability of Zirconia during milling is wonderful.  The other reason I do a lot of chairside zirconia and Katana is that I love the ability to cement on those deep margins or those patients where it is really difficult to isolate and bond well.  (I will say that Kuraray-Noritake does not advocate cementing Katana STML with RMGI)  To make myself feel better on these cases where I am not bonding Katana, I am making sure my fissure height on my design is 1.20mm or greater.

So here is a case that I just did.  Tooth #30 had gold onlay that came off.  

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I tend to choose a shade that is one shade darker than I am shooting for.  In this case, I wanted to match the shade of the occlusal 1/2 of tooth #29.  I felt like that was A1 so I choose A2 Katana STML.

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Deep recurrent decay that I removed and built back up to ideal. 

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It does take extra time but I do think there is significant improvement in esthetics with a Katana crown that has been glazed versus polish only.  In this case, I pre-polish my crowns before I sinter them.  Post sinter, I lightly air abrade the crown to take away the surface tension so the glaze will adhere uniformly.  In this case, I choose to use Empress Stain and Glaze and fire on P4.  

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I schedule all of my crowns for 2 hours so this isn't really a huge deal for me to spend the extra time for a glaze fire.  I tell the patients it will be about a 45 minute wait.  During this time I am doing another procedure.   I haven't received a complaint from a patient.  But our team does prep all patients before they schedule to expect to be at the office for 2 hours.  

Overall I'm quite happy with the final results and esthetics.  I know there are some that don't have a SpeedFire and doing Katana is not possible, but for those of you that do, I think Katana is a wonderful material and I am using it more and more.

03 Sep 2019

This is just one of those cases that meant a lot to me. This women walked in my practice looking for a third or fourth consult for her front teeth. She was celebrating 1 year of being cancer free after undergoing pretty severe chemo and radiation with low survival rates. She beat the odds but her teeth suffered. She had something to smile about now and wanted her teeth to reflect that. She hated her smile and I was so grateful that she chose me because I wanted to be a part of her story. 

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Major damage from erosion was done to teeth #7-10. The canines also show buccal erosion and pitting on the cusp tips. She has obvious tetracycline staining as well and in her smile we decided to work from #5-12 knowing that she could always add in #4 and #13 at a later date if she wanted. 

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When I am looking at the shape of her teeth, I see that the laterals are a bit wide, I want to lengthen #8 and 9 due to the amount of wear and erosion (meaning I have to pay attention to occlusion here) but I really like the overall shape of her teeth. 

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I set this up in the computer as Biogeneric Individual, but then manually add a BioCopy Upper folder so that I know where her midline, incisal length papillae are. 

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This is a case I delivered in one appointment and a tip that I have definitely learned over the years is to trust biology. I have a huge fear of black triangles and I know I am not alone. Patients hate the look of having pepper stuck in their teeth and are always asking if we can fix it. It's not an easy task with a tiny bit of composite for natural teeth, and then with crowns, I just used to make these long, broad contacts to avoid it at all costs. The problem with those long, broad contacts is that they just don't look quite right. Now it's this constant struggle in my mind of making sure there is no black triangle and trusting biology to fill in the triangle. 

Here is an example of that-

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Immediate seat

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1 week post op and praying to the papillae gods

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3 week post op 

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This was such a fun case for my entire team getting to know this woman who has more courage and strength than I could fathom. She affected every one of my team members in a positive manner and now can't stop smiling. She scheduled to do her lower anteriors in a month and I can't wait. She was an amazing reminder of why I love what I do. 

 

22 Aug 2019

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. embedded imageembedded imageembedded image

Hope everyone has a great weekend. 

22 Aug 2019

Posted by Steven Hernandez on August 22nd, 2019 at 07:59 am
View Comments (22)


Richard has been a patient of mine for the last eight years. He’s 32 years old, single, and an overall great guy. Earlier this year he made a consultation appointment for his front teeth to discuss veneers. When we finally sat down, I asked him what made him decide to move forward with this treatment.  He mentioned that he was tired of being single and knew that he needed to do something about his smile if he wanted to feel confident enough to enter the dating scene and find a life-long partner.

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We had a lengthy conversation about what he wanted to be sure I could meet his desire. His request was simple: make is teeth white. Overall, the position of the teeth was good; no ortho or soft-tissue treatment was required. As this was a straightforward case and the patient wished to begin treatment as soon as possible, I elected to begin without a wax-up. While this is not my normal protocol, I felt confident I could deliver and the patient would be happy.  A pre-op putty was taken and his teeth prepared. 

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CEREC images were captured and the putty was used to fabricate the provisionals. Even though the temps were the same shape/position prior to preparation, he was quite happy at the fact that his teeth were no longer discolored. Without a wax-up to copy, I decided to send the case to Weston Hatcher and allow him to design it. Weston and I spoke about the case and I let him know what I was looking for regarding facial anatomy (minimal to none), embrasures, etc. The final design was emailed back to me a few days later and the restorations were milled in-office.

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After the congratulations, handshakes, and hugs, I walked him to the front door. When he walked outside, he raised his hands in the air Rocky Balboa style and shouted, “I’m beautiful!”  Cases like these make all the tough days hard to remember. I wish the young man well in his social life with his new-found confidence.  These restorations are Emax BL4 and were hand polished only.  I chose not to add any incisal or cervical characterization as the patient’s primary desire was to have teeth that were simply one color.

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18 Aug 2019

This was patient had trauma to #7-9 many years ago, neglected her teeth and presented with gross decay and fractures.  She wanted a new smile and insisted on doing this in a single visit.  The software did a really good job with biogeneric individual proposals.  These are 7-10, Empress Multi A1, polish only.  I really prefer to not have the anterior's too glossy, when wet, they look very natural.  Since I have 2 mills, the entire treatment was completed in just a few hours.

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12 Aug 2019

With all the recent interest in Azento and Astra EV, I thought I'd share a case with a couple of tips to help you avoid a couple of complications I encountered during a procedure.

In this case, the patient was referred for an evaluation with suspicion of a fracture; the referring doc was unable to do find the fracture, and after I looked at her I could not locate it either. embedded image

I sent the patient to my excellent endodontist, who after accessing was able to find a fracture on the distal and returned her to me with a hopeless diagnosis for #30. We went through the now routine and simple process of capturing CBCT and CEREC digital impression, and uploading them for Azento case analysis and production. With the available interradicular bone, I opted for an immediate placement. Azento digitally removes the tooth and designs the guide as if it were already extracted. As this patient would be returning to her referring doctor for the final prosthesis, I chose the custom healing abutment solution only. When the patient came in for surgery she looked like this:

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Obviously the guide won't fit with the tooth in place, so the first step is to perform a coronectomy. I will typically use a 557 carbide to undercut the tooth following the gingival contours, first from the buccal and then from the lingual until the clinical crown becomes mobile. My assistant will keep the surgical suction on the occlusal of the tooth to keep it from relocating to new territory in the lung or gut. Once the clinical crown is safely gone, I will use whatever large coarse diamond is on hand (either a large football or an 845KR) to finish it down to where the guide will clear it. Try not nick or abrade the soft tissue too much as you do this.

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I prefer to complete the osteotomy with the roots in place; there are a few excellent threads detailing this process here on the boards. One of the benefits of this is that the distal curve of the mesial root that many mandibular first molars have is obliterated during the drilling process. This particular root is often the cause of difficult or complicated extractions. Once the osteotomy is complete, it's usually a fairly simple process to remove what's left of the roots and then thoroughly curette and irrigate the site with saline. When curetting the socket in cases like this one where there was some periapical pathology, spend as much time as necessary to achieve clean, bleeding walls. Once that is done, the implant is placed through the guide to the appropriate depth and orientation to accommodate the custom healing abutment; remember that one of the benefits of using EV and an Atlantis custom abutment is that the abutment fits only one way, and the guide helps you position the fixture so that it is timed correctly. Once the implant is placed (in this case we achieved approximately 25 Ncm on implant insertion), a good practice to follow is placing a cover screw while grafting the gaps around the fixture so that your graft doesn't occlude the internal aspect of the implant. In this case I used a cortical/cancellous mineralized/demineralized blend allograft, mixed with PRF, to graft the gap. Then I used a PRF "membrane" with a hole punched in the middle to drape over the graft. The hole is there for the healing abutment to go through, but if you undersize the hole you will see the PRF membrane distort as you deliver the abutment through it. The final step here is to suture, and in this scenario I will typically start with a horizontal mattress to pull the buccal and lingual gingiva against the healing abutment and underlying graft as much as possible, then follow with a pair of single interrupted sutures to tuck in the papillae.

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I ended up having to remove the healing abutment after the PA was recorded, as it was clearly not seated all the way. I used the larger bone profiler so I felt confident that was not the issue. Turns out despite the care I took to exclude graft material, one tiny piece migrated into the implant in the short time between cover screw removal and abutment placement. Always double check this as you're moving forward; not fun thinking you're pretty much done and then having to go back. This lead to another minor complication: when I put the healing abutment back on and hand tightened it, the PRF membrane distorted a bit and the implant/abutment complex rotated a few degrees. This is one of the aspects of using the Astra EV that can be technique sensitive; the threads of this fixture are not particularly aggressive. While the bone implant contact is very high in a normal osteotomy, and it is very important to keep the insertion torque value less than 45 Ncm to avoid pressure necrosis, the story is a little different in immediate cases. I used the V drill to finish up the osteotomy as I routinely do in most of my EV cases, and in hindsight this is where I erred. Since the implant is only partly fixed in bone, we need the torque value higher (45Ncm) vs the 20-25Ncm I ended up with after using the V drill. If you place the implant and are exceeding 45Ncm, you can always back it out and alter the osteotomy with the V or X drills, or the A or B drills, depending on the clinical situation. Once the bone is gone, however, there's no easy or predictable way to get that torque value back up. I was concerned that trying to reverse the complex simply to make the healing abutment straight or to make the PRF drape ideal might reduce the stability to where the fixture would fail, so I opted to leave them both. 

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The patient healed normally and had no further complications, and the referring dentist had no issues restoring the fixture.

I'm hoping the small errors I made with this fairly routine case can help some of you as you adopt this treatment modality and explore the varied uses of Azento and Astra EV.

 

Jeremy