Blog Author: Richard Rosenblatt
I saw the other thread about dual maryland bridges and this case was in my office today. forgive the pics immediate post op as I will not have time to take photos till later this summer when she returns from a school trip to Ireland. This pt has been a pt of mine since I bought my practice 11 years ago. she had 7 and 10 congenitally missing. we had her in maryland bridges made with lava ultimate since she was a soph in HS. she wore those for over 5 years and they held up well. I'll have to dig up pics of it. We used an HT block and it was a mistake. looked grey. she was happy to just have something while she waited for us to say she could get implants to replace the missing teeth. Very difficult access due to the lack of space between the roots of 6/8 and 9/11. she went back to ortho and they put her in invisalign last year to get more room to place some thin implants. We removed the Maryland bridges and she wore her aligners while back at school. Mom tells me that her daughter is going away to Ireland for a few weeks this summer and really wants this implants in to heal over the summer so she can have these restored sooner rather than later. Her daughter was coming home on may 7th and leaving on the 25th so this did not leave a lot of time. We needed to take a new 3D scan, cerec scan, plan the implants, make the maryland bridges, have the implants placed and seat the maryland bridges in less than 3 weeks.
She came in and I removed all the buttons from invisalign and scanned her upper, lower and BB. I took a new scan. I do not have a printer and my MCXL is one of the originals so I can't mill guides. This is where the beauty of this community comes into play. Dave Honey works in the next town. He lives close to me too. I contacted him and he was able to mill a guide and get me keys to give to my periodontist this past monday. The surgery went great. He put in healing abutments, stitched her up and told her to wait a few days and come to me to get the restorations bonded in. Dave, you are the best and thanks so much for your assistance to make this happen in the time frame we were stuck with.
She just left the office. I had to adjust the underside of the maryland bridge to allow them to seat over the healing cap. These were lava ultimate shade A1LT with wings on the canines. The stitches are still in. she is having them removed next week right before she leaves. I don't like the position of 7 when I look at the photo because it does not come in mesially enough for my liking. that being said, she is very happy to have the permanent solution. My perio wants her to wait till xmas to restore these. He is fantastic so I'm not messing with him. She has an invisalign retainer she was wearing with the fake teeth in 7 and 10. we'll take off the maryland bridges when she is home for xmas break and then have her wear the retainers while we make the final crowns. I'll take photos of what she looks like when she returns so we can see tissue response and such and then I'll post the final case next year when we seat. This technology made a much easier surgery for my periodontist. It allowed me to get him a guide in a very small time frame. It allowed me to make fixed temporary restorations and I was able to rely on a friend and fellow cdoc community member to help me out in a time of need. I love the place and I love this technology.
I have intra oral cameras in my 4 ops. 2 of them have digidoc cameras and at midwinter I splurged on a trans illuminator for one to see if it would help me show patients what a crack can look like or to see decay that may not be easy to see with BW. This was a case from today that the pt will be doing 2 crowns after seeing the photos. I tell people all the time to take lots of photos to explain to patients what is going on in their mouth. It allows them to see it and take responsibility for it. This is from today. I love investing in technology that helps us communicate with our patients. they say a picture is worth 1000 words, but it this case it was the pt realizing she needed 2 crowns to protect those cracked teeth.
Just wanted to show this screen shot of the lower image I took today. Pt had perio surgery on 18 and I removed her old crown, the recurrent decay, and was prepping for a new one. How the hell would someone get an impression tray on this pt?? Her tori were just humongous and there was no room for a tray there. She was so happy to not have that issue with the tray cutting her and tearing up her tissue. I was just happy to easily be able to image the lower so easily as if those damn things were not even there. One of the hundreds of reasons that digital is so much better than analog!
I just wanted to post some screen shots from a screw retained implant case that I just finished last week. I try not to have too much lateral function on implant restorations. I just always was taught that function down the long axis of the implant would be tolerated better long term and hopefully improve longevity. This case has 3 implant retained crowns. I did 13 and `14 a few years ago and 12 was a crown on a natural tooth. the tooth had very little support and I tried to convince her to get 3 implants or 2 and a bridge but she wanted to try and save it. 12 fractured to the gumline and she ended up getting that 3rd implant. When I image for implants I now image across to the contralateral canine because I have found using the articulator function has really helped to dial in my occlusion and eliminate these potential lateral interferences. Here is the scan and the intial proposal and some work I did on it from both straight on and from the occlusal shot.
as you can see from the image from the occlusal view, I took the occlusion to a navy blue and removed all the maximum intercuspation interferences that I could see. Normally this would be pretty perfect, but sometimes I'd have to adjust some excursives. I decided to look and see if I had any excursive interferences. to activate the articulator, first you must activate it in the configurations. here are some screen shots of how to find it. Configurations-->options--->articulation once in there activate the options for the articulation but not to use it on the intial proposal. I found this really takes a long time to process and I don't need it for every case
Once I you have activated the articulation in the configuration, you can select it for any case. In this case, after the proposal I went back to administrationan and clicked on the articulation icon and it then activates it
Once I do that I click on the articulator icon in the design page and it will show my any excursive prematurity with the occlusal compass. In this case I was hitting near the cusp tip on the incline of the occlusal table above the screw hole.
I can then just use my circular shape tool to remove this interference and have a restoration that I did not have to do any adjustment to other than polishing the composite over the access hole.
This does not have to be used only for implants but its when I tend to use it most. If you plan on using it, just make sure you image to at least the contralateral canine to give the software the necessary info to get us the most accurate results. Hope this will help you dial in your implants and bigger quad type cases.
This is a newer pt to the office. She is a doctor and always tells us that she does not have a lot of time to come in for appointments due to her busy schedule. She called a few weeks ago telling my receptionist that she broke a veneer on the upper left and needs to get in ASAP to fix. She is very nice but very picky. I'll include a pic of how she showed up in our chair with the broken veneer on #11. The veneer she had cracked at the incisal edge. It was 9 years old. I took some composite and filled it in so I could bio copy it.
I told her it would take me about 90 minutes but she'd be leaving with the final. She could not believe it. Kept repeating that this was not possible. She came in today so I took a quick pic of the final. She told me she liked the final better than the original because I wrapped the prep to the lingual and she could not see the margin that was visible on the original. She left the office telling us that she is going to tell everyone she knows that if they need cosmetic work that they need to come to us.
The power of 1 visit dentistry, especially when it is in an aesthetic area, can be a great practice builder. when patients think you can do something that no one else can, you separate yourself from the rest. The last pic is the final of the veneer on #11. Not a huge deal, but a nice color match and she was very happy with the final result. She came in today to take impressions for a night guard and kept letting us know how much she appreciated getting the final the same day and how much she loves how it looks. I Love me some CEREC!!
I was doing a basic training last week and I received a question that I hear often from new users…..”How should I schedule my CEREC appointments when I get back to the office?” I tell all new users to schedule for success. What that means to me is that the new user must understand that things initially will take a bit longer since they are learning something new and they need to schedule accordingly. Trying to stay on time is not easy in a busy practice. Throw in some new technology for the team to try and master and it can add some pressure. My suggestion to my docs is to do one of two things. My first suggestion is to schedule about 2 hours for your first cases and schedule them up against your lunch and the end of your day. By doing this, if you run late, it will cut short your lunch or you may stay a bit later, but at least your schedule won’t have added pressure. The other suggestion is to book it on a day for the first month that you are not usually in the office and do three or so cases when there are no interruptions like hygiene checks and emergencies.
The other recommendation I have is to download the cerecdoctors.com app and use the “Track a Case” application. This will allow you to time each aspect of the CEREC appointment such as anesthesia, imaging time, prep time, design time, milling and cementation. You will get an idea of what aspects of the process you are progressing well with and what areas you may need to work on. It is a very handy tool to help you improve necessary aspects of the CEREC appointment. Once you get an idea of how long your appointment is taking, you can then start scheduling more procedures and also understanding that in the milling and characterization aspect of the appointment, you can start to schedule other dentistry to maximize profitability.
I just had my annual maintenance on my Omni and MCXL this morn. Patterson techs do such a great job when they come out. They really know the machine and give lots of great tips on maintenance for our daily routine. I got a good one today that I thought I would share. He told me that the water jets that shoot water to the tip of the burs had some clogs in them. For those that don’t know where the water jets are, this is a close up of the 3 small holes where water is aimed at the tip of each bur.
These holes can get clogged occasionally with some of the milling debris. If all 3 jets are not hitting the end of that bur, you are going to go through a lot more burs than you would like. Try these steps:
- Close the lid and hit the pump button. This will purge the water through the jets and let you see if water is coming out of all 3 ports. In the pic I have included, you can see water is coming out of all 3 but the tech told me that I had a few that were not firing water to the tip of the bur.
- Once you determine which ports may be clogged, get a 15 or 20 new endo file and insert into each individual port. You can see by the pic that there is a definitive angle you need to get to insert the file properly into the port. Do this with each clogged port and then try the pump button. Repeat until all ports are clear and freely flowing.
He recommended doing this weekly when we change the water to make sure it stays clear and free flowing. I now have my mcxl and omni with new filters, cleaned, calibrated and ready to take on whatever I can bring it. Thanks again Patterson for you service and knowledge with this technology!
Has anyone had this happen when you use spray glaze? You spray the crown to get your nice glazed finish and put it in the oven. You go to take off the crown and firing pin from the tray and you snap the bottom of the peg and it is stuck in the tray!!!
This has happened to me 2 times. If this does happen, you are likely going to have to get out a bur and run it over that to knock it out. The reason this is happening is that you are putting the crown and pin on the tray, holding the tray and then spray glazing it.
When you do this, the glaze will get into the hole in the tray and cause the pin to get stuck. What we do to avoid this is 1) to make sure you do not spray glaze the restoration on the tray and 2) hold the pin by the bottom so no spray gets on it and causes the same problem. Simple fix for an annoying issue that occurs for spray glazers.
When restoring a maxillary tooth with CEREC we take our necessary images, stitch our Buccal Bite and then go to the Model Axis. When we get to the Model Axis step, we see the mandibular model and not the maxillary one. The bases the model axis to the mandibular arch but that does not mean that you can’t see it and adjust it if you’d like to.
In this example, a crown is prepped on tooth #3. When we get to the Model Axis stage, we can see the lower arch. We try to line up the cusp tip of the canine to the distal buccal cusp of the second molar in the bottom left window. On the top left window, we set the model so we can see the buccal and lingual aspect of the arch equally when we look down the long axis of that tooth. If you want to see the maxillary arch, click on Display Objects and you will see that you have the option to click on the maxillary arch. When you click on the maxillary arch option, you will see you prep and can make minor adjustments if necessary.
I really like this combo because it mills nice, polishes nice and cleans up easy. Patient broke #30 DL cusp. The tooth had some recurrent decay. I checked it with caries detect. The tooth was slightly sensitive to cold but 1-2 seconds on cold exposure and then no more discomfort.
The procedure start to finish was about 65 minutes. I like to do partial coverage whenever I can. This is a typical case for me that gets partial coverage.
To learn more about this case visit https://www.cerecdoctors.com/discussion-boards/view/id/37973