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We have slowly but surely increasing our Sleep Appliance "practice within a practice", and I wanted to post a case and find out how many of you are doing OptiSleep as well as hear how we can all work together to make it better.
So far, our cases have done very well, and the patients love them. We still do a few non Optisleep appliances due to limitations in the system, but the Optisleep appliances fit so much better than anything on a model based system I only want to do those.
Here's a case I sent out today that we recently scanned:
Make sure to take time to send the scan to BeamReaders or make your own chart notes about what you see in the imaging. Here, we see arrows pointing to some potential (asymptomatic) condylar "bird beak" type of deformity on the anterior part of the condyle. We'll keep an eye on this. There is also an engorged nasal concha as well as a slightly deviated septum. We recommended that she use Flonase (OTC now) and see an ENT if she has persistent sinus pain or fullness, or nasal congestion. Everyone wants to go right to the narrowed airway, which is fine, be make sure you document anything else you see. If you have any quick questions, please post a screenshot and I, or even better, TK will give you some advice.
Here's just the pre treatment Sicat Air screen. Significant airway constriction in the oropharynx, and no nasopharyngeal or hypopharyngeal issues. Make sure that they position their tongues down and somewhat back to better approximate where the tongue would be while they're sleeping.
Then comes the George gauge. We set everyone at 60% of maximum protrusion. When we have Zephyr we'll make it custom, but for now we're trying to be consistent, and patients are tolerating it well so far. Please make sure you have 5mm of space between the arches, or you'll get the naughty note from the Sicat techs, since less than 5mm gives them insufficient room to make the appliance. With this in place, we take a new CBCT, and here we tell them to keep their tongue forward as will happen when you move the mandible (and the genial tubercle) forward. You can see that we got significant improvement in the airway space. I will say that there isn't always a huge red to green transformation, which worried us at first, but we've had great consistent clinical feedback from the patients as to how well they're sleeping so we worry less.
Hopefully some of you will post about your SicatAir experiences. We're hardly experts, but we keep on trying to get a better and smoother workflow.
I know others have posted different techniques using other softwares to execute Essix retainers. I don't think anyone has done it the way that I have though, so I thought I would share...
If you have heard me speak about my feelings on 3D printing, I love it.... BUT, I will not completely love it until I can be 100% digital for all procedures. Now theoretically you can do that now, but I want it to be efficient. That is, I currently mostly print models and guides for esthetics and implants. What I want is to be able to handle everything from bleach trays to essix retainers, etc... I basically want to eliminate all impression materials completely from my office. For this, 3D printing needs to be fast and also a bit more automated I believe. Once that is the case, I would certainly be willing to pay more for a 3D printer if it had more applications like this.
So.. here is a case I did with the inLab software. I know that most of you do not have the inlab software (in US), but it gives you an idea of the possibilities that hopefully we will see at some point.
Patient missing tooth #26. Has been wearing an essix retainer long term that he broke.
Scanned with the Omnicam:
Exported .stl high resolution and loaded into inLab 18. From there, designed a crown in the space:
After design, virtually seated and added a base to it:
3D printed it in grey resin (100 microns Z)
Block out undercuts and used Ministar and 1mm Clear Splint Biocryl :
Now, the best part... go into inlab 18 software, reverse the virtual seat and choose the original layer, export the .dxd file, import into CEREC and then mill the tooth (composite block). Then insert it into the Essix...done.
There may be cheaper ways to do this, but this was super easy and my guess is that it will be very predictable. That is what is important to me.
I live in a college town so I see a lot of college students who end up having a bit too much fun on a Friday night and experience dental trauma. This patient presented with crown fractures of #8 and #9 with the pulp of #8 evident but not obviously exposed and #9 pinpoint pulp exposure.
Of course, she is about to head home for summer break so I won't be able to do any follow up for the next ~3 months.
I used a bioceramic for a pulp cap of #9 and then I prepared the teeth for crowns as conservatively as possible (especially on the lingual leaving the cingulum intact) and milled crowns out of Empress Multi to be used as provisionals. My rationale for cementing these as provisionals rather than definitively is in case either of the teeth become discolored or need RCT.
I plan to see her back in the Fall to evaluate and proceed with the final restorations.
Would anyone do this differently if they were in my shoes?
Are you quadrant CERECing? The single CEREC restoration is a very productive and profitable procedure in our practices. But, the profitability increases exponentially when we begin to perform a quadrant of CEREC restorations or treat additional restorative needs during the same appointment.
In my practice, a single-unit CEREC restoration that is fired may take around 1.5-2 hours depending on the case, but adding an additional CEREC restoration only adds about 30 minutes to the overall appointment time while doubling the production. In other cases where a patient only needs a single-unit CEREC restoration while needing direct composites, the appointment time may not change since the milling and firing times can be leveraged.
Here is an example of a quadrant CEREC case I completed last week. This 80 year-old patient had decay on #21 and #22 (not pictured) and failing restorations on #28, #29 and #30. The treatment plan included: #21 MOD composite (not pictured), #22 DIFL composite (not pictured), #28 DO composite, #29 full-coverage crown and #30 full-coverage crown. Emax LT, shade A4 was used to restore #29 and #30 although I could have used a C or D shade if I had it. The entire procedure took 2 hours and 20 minutes and produced around $2800.
Here is the overall timeline detailing my role and my assistant's role for this particular procedure.
Always scan the teeth past the midline to the contralateral central for the best proposals with regards to anatomy, contours and marginal ridge heights.
When treating 2 or more teeth with the CEREC, make sure to marginate all the preps before moving forward and always double check that you've marginated the correct tooth.
Once the CEREC proposes the restorations, choose the restoration that is closest to being finished with regards to design. That way, it is sent to the mill as soon as possible and the next restoration can be designed. For this case, in my opinion, #30 appeared to require less design work, so I started with this crown first and sent it to the mill.
After the first restoration's design is finished and sent to the mill, begin designing on the second restoration to leverage the milling time.
Here is the final design of both restorations.
The restorations were tried-in after milling to make any adjustments to the contacts.
Here is the final photo of the restorations bonded and delivered.
There are many different ways to be efficient when treating a quadrant of CEREC restorations such as having an extra milling unit, delegating aspects of the CEREC workflow to the assistant, treating additional restorative needs, using the Ghost Contact Technique, etc. If you've been intimidated to use the CEREC for multiple units, set a timeline with your team outlining what you will be doing, what your assistant will be doing, if any hygiene checks are needed, etc. Level 4 also teaches how to be efficient with quadrant CEREC dentistry.
This is one of those cases that is just so much easier because of my CEREC.
Pt comes into my office with large existing amalgam restoration on #31. She has recurrent decay around the entire lingual margin of the amalgam restoration. If I didn't have my CEREC and the ability to use Biocopy this could be a difficult appointment.
I anesthetize the pt and my assistant scans the case into the Biocopy catalog. She then copies the information into the Lower Jaw catalog. In the Lower Jaw catalog, she uses the Cut tool to remove #31.
I prep #31 for partial coverage restoration. I know there will be multiple opinions on whether full coverage or partial coverage should be used here and also on material.
Personally, in this case I prefer partial coverage and also prefer GC Cerasmart for restoration. This pt is 87 years old, in an assisted living facility, and Im not sure how often the partial is removed, despite our pleas. If I used a material such as e.Max and she returned in the future with recurrent decay, the entire restoration would have to be removed. With a material like Cerasmart, it can be repaired intraorally with a direct composite.
Start to finish she was in our office for just under one hour. She left with a big smile, not having to go without her partial while a restoration was fabricated at a lab!
So I have been working on this case for just over a month and delivered it today. Patient had CC of misaligned teeth and failing composites. Declined ortho, don't blame her she is 71. However, she was made aware of how much I was planning to "pull back" her teeth based on our waxup and how everything overalyed with CEREC. So again, here is how I used our technology and software to our advantage.
I scanned the patient with the 4.5.2 software and exported the STL files. They were sent along with photos via dropbox to my lab with instructions on the case.
We received the mockup back as an STL file and printed using Form Lab 2 printer.
I opened her case back up and then scanned the digital waxup and overalyed to show the patient at her consult. After she agreed with proceeded with the case.
We rough prepped the teeth and delivered the mockup to the mouth, using it as a reduction guide for the case.
When I tried to deliver the bisacryl temps, I nor the patient liked the midline, it was slightly off. So I used the digital model and editted the design and milled out Lava Ultimate temps. This is how tissue presented after 2 weeks.
After approval of the provisionals, we printed her prepped arch and milled 4 vita mark 2 crowns. Here is the following lab process:
These were delivered today. So we will get the patient back in a week or two for finals. But really thrilled with the outcome. I didn't see the "junk" until after the photos .
These types of cases have become very predictable in my office. From sending it digitally to the lab and visually seeing how much we are removing, to having a model ready for fine tuning the restorations, I think 3D printing is taking a big part of our digital dentistry arsenal.
Webinar synopsis: This webinar will show in detail how important the Digital Workflow is for blending the Orthodontic, Surgical and Restorative treatment plans. The webinar will also show the importance the digital workflow in an orthodontic case when the patient is unable to come to you office on a regular basis.
Dr. Jeffrey Briney is a graduate of Indiana University and practices in Dana Point & Laguna Beach. He speaks around the world with regard to his personal approach to Surgical, Laser & Restorative Dentistry complimented with Facial Esthetics & Orthodontics. Dr. Briney can be reached at email@example.com or through his website www.drbriney.com.
I’ve been a Cerec user for over 9 years and I am continually amazed at what this technology allows us to do for our patients. I saw this 20 year old patient last week for a consult to have her veneers on 8,9 redone. She had a large composite on 8 from trauma. The previous Dr made 3 attempts (with the patient in temps for 3 weeks in between each try in) to please her and the final attempt she had to drive across town for a custom shade and still wasn’t happy with them. A few weeks later she had some porcelain chip at the facial margin and the Dr refused to see her according to the patient. Her story raised some red flags to me and I was a little nervous I would be able to please her. After examining her existing veneers, they did appear too long and bulky and the surface texture, shade also didn’t match her existing teeth. She was blown away that I could remake them in one 2 hr visit. I used emax BL3 and the cerecdoctors meisinger polishing kit to add texture and polish prior to stain and glaze. She loved the results and her mom has an appointment this Monday as well. I love what Cerec single visit Dentistry gives us the power to do.
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I much prefer to post cases that are a slam dunk and turn out looking beautiful like this pre-op and 4 year post op case....
But unfortunately, some cases don't go this way. I hesitated to post this failure, but I tend to learn more from the cases that don't work out. This patient has broken almost every restoration that anyone has placed. She fractured the endodontically treated tooth #14 and I extracted it. I think I only waited 3 months to place the implant.... maybe too soon for this patient. I also went with a shorter implant to avoid sinus grafting.... mistake? Maybe with this case. I let her heal for another 3 months and placed a screw retained e.max/TiBase restoration.
Over the course of about 9 months, things went from bad to worse. I took the crown off, put her in a healing abutment, and grafted, but nothing worked.
So now what? The patient is asking for a bridge, and I'm honestly afraid that she'll fracture the retainer teeth in a few years. Like a lot of you, I offer to re-do everything for free. Right or wrong, she agreed to a new implant, so I changed everything about how I did the last one.
I did a sinus lift, with a bigger, longer implant and re-grafted.
I went with an Atlantis abutment ( I do think a TiBase would have been fine on this case), and I put the softest material I could think of on top, Enamic.
Although I kept the occlusion light, the patient still was functioning heavily on the crown. When she bites hard, I think her natural teeth move apically a lot more than normal.. this is the wear on her Enamic crown after less than a year (delivery and about 11 months).
She appears to be doing well now as far as bone levels around the implant, but time will tell. In the end, I waited longer, grafted more, used a bigger implant, better contour abutment, and softer crown to try and take up some force. Maybe none of this mattered and the case failed for other reasons, but hopefully this is the end of a very long story :)