Blog Recent Articles
This case was one of the most challenging esthetic and structural situations I've ever been faced with. We knew going into this case that it was going to fall far short of ideal because of the poor position surrounding the existing implant #9. It was an old Calcitek implant that was placed far too deep and much too far buccally. We made the easy decision to bury the implant in favor of a FPD #8-9-10 and have the periodontist perform hard and soft tissue grafting to gain as much bulk as possible in the ovate pontic #9 site. Here's what he was able to accomplish:
As you can see, even after extensive grafting there was still a considerable vertical defect remaining. So I made a mid-crestal incision and used pressure from the ovate pontic to push the tissue as far facially as I could. We were still quite deficient, so I then injected Juvederm hyaluronic acid filler into the papillae and facial tissue to shape it around the provisional bridge contours. Next, I had to deal with the very dark stump (ND9 prep shade) on endo-treated #8, so internal bleaching was performed using sodium perborate. This took the stump shade from ND9 to ND3, making the difficult block-out much more manageable...
The next challenge was to match the very translucent enamel on her natural teeth with the e.max LT bridge block. To attempt to accomplish this, I milled an LT BL2 block and layered lavender stains first, followed by some brown chroma, and finished with a white-wash to match her striated enamel. After several layers of stain/glaze characterization, we ended up with approximately B1 as a final ceramic shade. It's not perfect, but here are the before and after shots:
After struggling with every aspect of this restoration, the biggest take-home message I learned was: once the soft tissue becomes deficient, it's very hard to recover and create a truly natural look. The papillae loss meant we would never have a biomimetic result, but we pulled out all the tricks to make it as natural-looking as we could. I'm honestly just very happy to have this one finally completed, even with it's shortcomings.
The answer is that I don't know yet... just messing around with some fluorescent infiltration with the abutments... can get the abutment to really fluoresce like natural dentin. If you use a translucent veneering structure like e.max HT... You may get a more vital restoration. Interesting stuff!
Rich Rosenblatt did a great post about the articulator function and using it when doing implant crowns. Here is the link: https://www.cerecdoctors.com/discussion-boards/view/id/53970
It got me thinking about something I have been doing regularly.
About 8-9 months go I started a little experiment in my office. I started using the articulator function that is built into the software. My reason for doing this was two fold. First I wanted to see how accurate the articulator is and also to see if it would reduce my post op adjustment.
As a lot of us have come to realize e.max does not mark very well with articulating paper. That coupled with a numb patient make it hard to see excursive interferences. The topic of post op sensitivity with e.max comes up pretty regularly on the cerecdoctors.com boards and inevitably, after the recommendation of checking the occlusion for interferences, the sensitivity goes away after adjusting. This got me thinking about using the articulator to find these problem areas so that we wouldn't have to have the patient calling back with post op sensitivity and needing an adjustment.
This is also an advantage when dealing with zirconia. Adjusting zirconia is not only difficult but also it is imperative that the zirconia gets brought back to a good polish to prevent wear on the opposing dentition. So the less we have to adjust the better, especially since we can't try it in until it after it is sintered.
Here is a case that shows the use of the articulator. This patient has an anterior open bite and group function. If we did not take into account the excursive movements then the chance of an interference is high. Which of course will lead to a need for post op adjustments and more chair time.
This first step is to make sure the articulator is active. This is done by going to Configuration->Pptions->Articulator and checking the active button under use articulator. I do not use the articulator to get my proposal, I just have it active to be able to use the articulator. Once this is done any case you open up will be able to have the articulator turned on. This is done in the Administration phase.
To use the articulator function and have it be accurate you need to image to the canine. Which is what I did until recently. Now that it is advantageous to image to the mid-line, I go ahead and image to the contra-lateral canine. This helps set the model axis by making it easier to set the curve of Spee and Wilson. This will give us a better initial proposal and sets the articulator up properly for the best result.
Once the initial proposal is given the distal marginal ridge is slightly lower than ideal.
This is quickly adjusted by using the 4 Direction Anatomical Shape tool. This ends up raising the occlusion to much and needs to be adjusted.
Once adjusted the proposal looks pretty good and should be ready for the milling chamber.
However if we turn on the occlusal compass we can see where we will have interferences that will lead to post opertative sensitivity. The Occlusal Compass is found under the Articulator menu.
Once the compass is turned on you will see the areas that are hitting in the various movements. You can turn of each of the various interferences to see which ones are present and which are not. Then use whichever tool best fits to make the appropriate adjustment. In this case the 2 directional circular shape tool is used to reduce the height of the cusp.
This gets rid of all the excursive interferences. The compass is turned off and the regular occlusal map is visible again.
As I stated earlier I started doing this about 8-9 months ago and have seen a drastic decrease in post op adjustments and sensitivity. By using the articulator to reduce the amount of interferences you can decrease the number of post op visits and occurrence of sensitivity for your patients.
The long and the short of it is use the articulator function for better results on every type of case.
I feel the integration of cone beam CT and the CEREC technology is one of the most amazing things available in dentistry...there is very little that enhances the patient experience more than getting to see the level of detail we go to in order to ensure that they receive the best possible treatment. I had the pleasure of presenting at Patterson's Technology Summit in December to demonstrate the integration and workflow we go through when planning implants, so their TA's could have a better understanding of the process when helping out the dental offices they support. I have noticed lately that several people have asked for a reference about the process, so I thought I would share it here in the hope it answers some basic questions for our community.
So, what do we need? Well, a BlueCam or OmniCam, the Galileos, XG3D, or SL 3D, the Galaxis software, and an SSI export license. If you are planning to mill your own guides, you need to ensure that you have the most current versions of the software.
We begin with the CEREC...we will designate the edentulous area as a crown(the material is irrelevant):
We will then want to take a nice scan to the contralateral canine(note that we do not need an opposing or a bite):
We will then design an ideal crown-contact strength is not important, and obviously we have no opposing so we aren't concerned with occlusion. Simply design the crown where you would like it and ensure it is appropriate in the arch form:
We will then advance to the mill screen, where we will export the file onto a usb drive:
These are my USB drives of choice:
The key to this is that we are exporting the SSI file, NOT the RST-this is only possible if you have the SSI license:
Next we, will open up our cone beam scan and start working through the software:
Once we have identified our nerves, we will click on the CAD/CAM tab and import the SSI file into the software:
We verify that we have the proper file and then go about the process of stitching it to our scan:
Now, it is time to plan our implant:
And here is our final plan, with the implant planned safely away from the nerve and centered under our desired final restorative outcome:
And at this point, we are ready to order(or mill) our guide:
This process allows us to place the implant easily and predictably, which also helps make the restorative phase very smooth:
Hopefully this helps some users out there as they are working through the integration process...time to gear up for the Super Bowl tomorrow!
Watch Dr. Mike Skramstad as he discusses the key features and important tips for optimizing outcomes with Celtra Duo, a fully crystallized, tooth shaded block with dual processing pathways.
Purchase a Premium Membership
to watch the full version of this video plus hundreds more.
We all have this happen to us, our schedule laid out the way we want for a productive smooth running day, then something happens to throw a wrench in it. My Wednesday morning I had a crown on #8 to start the day and then an implant right after that. The crown patient came in with the crown #5 off at the gum line.
Now we have a problem. I only have one room set up for implant surgery. I don't have time to make a guide for this case, get the tooth out and place the implant before my next patient comes in and needs her implant placed. So the decision was made to go ahead and extract and place the implant free hand. Normally implant surgery is done with a guide in my practice. There are times that either the guide doesn't fit or fabrication of the guide is not feasible. This is why it is important for doctors to have the surgical abilities to place an implant free hand.
The plan in this case was to split the roots and place the implant in the interseptal bone to get primary stability.
The roots were sectioned with a high speed hand piece with a long shank surgical bur. This serves to purposes. One is to make the removal of the roots easier. Secondly it also gives a guide for the drill to not kick buccal or lingual during preparation of the osteotomy. Now all we need to do is manage the mesial distal position during the osteotomy preparation. Having the CBCT did however help show where we needed to section the tooth and how deep to go to make sure that the tooth was sufficiently. Unfortunately due to the time constraints trying to get the case done before my next patient gets here I didn't get a photo of the sectioning. Once the osteotomy was finished the roots were removed atraumatically. The implant was then placed with 35+ncm of torque and the root areas were grafted with cortical/cancellous
Could this case have been done guided, sure but I would have either had to reappoint the patient(they are not the most reliable patient) or run behind and make my next implant patient wait. As it was the patient got the tooth extracted and the implant placed and we were on time for our next patient. Guides are great but ultimately the surgeon needs the skills to know how the surgery should go even if they don't have a guide.
I have been posting a lot lately on infiltration... tried it today on a zirconia abutment (Incoris F0 Meso). There is a of pictures here.. but I thought I would post a full protocol!
Initial Situation. Heroic "try" with aggressive prep. We knew it would not work long term... was done 9 years ago
Implant plan on #12. Based on the plan and screw access, I knew I was going to do a screw retained restoration.
Healed implant 5 months later ready to restore:
Took images into CEREC
Final design... notice position of screw access compared to initial Galaxis plan:
Infiltrated with A3 Vita Liquid:
Sintered in SpeedFire:
Torqued into mouth:
Just an update on infiltration. I have been messing around with the Vita YZ HT liquids based on a couple recommendations. Like everything it's a work in progress, but I like it a lot. Seems to be pretty intuitive and the colors really come out nicely. I think there are some good methods to lower the value of zirconia using a couple different recipes...
Here is just a really quick one I did this afternoon between patients messing around. It was an A2 block with A3 shade in the intaglio and cervically. An A chroma shade in the fissure and Blue on the cusps and ridges. I got the "A chroma" a bit sloppy and I think i'm going to try the pens on this to make it cleaner.
It's definitely got some potential for sure! This is obviously just polished.
The mantra goes "pink esthetics before white esthetics" and I thoroughly agree. What our scalpel-wielding friends can achieve for our patients is truly remarkable. Here's an anterior restorative case with combination clinical/esthetic crown lengthening that simply would not have been possible without perio surgery:
I can see the issue because of your excellent photography but I submit that it is not noticeable to the naked eye at conversational distance and nobody cares about this but you. However, if you can sell it to the patient, God Bless You. The people I see would laugh me out of the operatory.