Blog Author: Anthony Ponzio
Just wanted to present a fun and interesting case that I just completed this week on a wonderful English gentleman. He presented about 1 year ago with failing RCT's and resorbed roots on teeth 8 and 9:
After discussing options, it was determined that extractions and implants would be the best plan. We discussed gingival zenith issues, and due to a low smile line and him not being concerned about it he did not want to pursue excessive grafting with the surgeon. He asked if we could space out treatment a bit, so we began with #8. I fabricated a flipper for him(which he hated) and sent him to the oral surgeon for extraction and grafting. A few months later, on the day of his implant surgery, I received a call from the oral surgeon, and he mentioned that our patient was asking if we could put a tooth in so he did not have to use the flipper any more...the surgeon informed me that he was comfortable with the insertion torque and that I could place an immediate provisional-and they sent him right over! Time to scramble...the OS placed a Nobel Active 5.0 so I placed a scanpost and imaged:
We then milled out a Vita Enamic IS block, left it out of occlusion, and undercontoured the facial in the gingival 1/3 to avoid gingival pressure. Unfortunately, because of the lack of time to prepare properly for this curveball, the only shade I had on hand was 1M1:
Now, this is part of why he is awesome-when I told him the tooth was too light, and that we could mill another one later, he told me he loves it(he would have loved anything to get rid of the flipper) and that he would stain it down with Earl Grey!
A few months later, he went back to the OS for removal of 9, and this time the OS did an extraction and immediate implant, and informed me that I could place an immediate temporary in this site as well. When he returned from the OS, sure enough he had worked #8 into a better blend! We then fabricated an Enamic IS for #9 and let the patient heal:
Now, please note that #8 is slightly longer than #9-the reason for that is...well...I hadn't noticed in the process of the appointment. No other real excuse:). A few months later, he returned for the next step in the process. Now, with the access holes through the facial, I clearly knew I needed custom abutments, so this seemed like a perfect time to try out the Atlantis workflow. Note how nicely the gingiva responded to the temps:
We placed the IO FLO scanbodies and imaged-you can tell the funky angulation of the implants in the scan images:
Within 24 hours, the following file was available for my review:
So, bounced that over to my buddy Dan Butterman, who suggested some minor edits for me(thanks Dan!). He also pointed out that it did not have me set up for gold hue abutments, which I thought that I had requested-so make sure to double check when ordering...they very quickly sent me an updated plan, which I approved:
Now, one lesson I learned is that when imaging the IO FLO scanposts, the scanbody folder should be well-imaged. I had scanned similar to a chairside case, where I capture a clean image in the maxillary arch folder and then the detail of the scanpost and enough data to stitch, but when they sent back my Core file an area I had not imaged well was causing an issue:
Reached out to Atlantis and they sent a corrected file, but just another thing to watch out for. After a couple of days, I received my abutments and used the file to design and mill out my crowns. It was a very easy process and all we had to do was design two crowns. They fit the abutments perfectly, which was pretty cool to see:
Finally, delivery day, after the patient returned from a trip to China, where he informed me he drank enough tea to take everything down another shade or two. The Atlantis abutments fit perfectly, without any discomfort for the patient. He was right about his trip-the crowns were a little too light initially so we refired them with some additional stain to bring them down a bit:
Final crowns were e.max A-2 MT. Obviously, the gingival heights ended up asymmetric, and I missed on the DI line angle of 9. We had one fun exchange along the way where he told me "I don't want perfect teeth-I am English." To which I replied "Then you came to the right dentist!" This was a fun case, mainly because he was an awesome patient, but also because I got to use the technology in such a variety of ways...always amazes me the flexibility and options CEREC gives us, and this Atlantis workflow was really incredible. Thanks again to Dan for taking a look at this case to help me get on the right track!
Just finished a fun case that I thought I would share...patient presented as a 27 year old female unhappy with her "dark tooth" after having root canal therapy due to trauma on tooth #8 as a teenager. She last had it bonded about 10 years ago, and the color has been dark for awhile:
So, we discussed options, and I had her see the endodontist to see if they could do some internal bleaching to give us some help prior to restoring the tooth. Her natural teeth were in the A-1 range, so any improvement would be helpful...after bleaching, we saw a little improvement:
So, onto the restoration...as has been mentioned previously, these single central incisors are so much more fun with the ability to mill, texture, and characterize chairside for our patients. In this case, we went with e.max A-1 MT. Textured the restoration post-mill, and then glazed and fired...
In reviewing the post-op photos(taking and reviewing these regularly has really made a difference for my self-assessment), it appears I may have gotten a little too aggressive with the white stain on the distal line angle...I also think I could have rounded the disto-incisal line angle a little more. What we see in the photos that I feel really made the case work is the way the texture allows light to properly reflect off the tooth surface and mimic the adjacent central:
Had a really crazy week last week, so just felt the need to post a case that I was overall pretty happy with to send some good vibes into the universe! I encourage anyone on here to really continue to take photos and analyze your work. It will pay off big time with future cases, not only with your ceramics, but any esthetic work you are taking on.
Just thought I would present a case where I had screwed up(I have plenty) earlier on in my CEREC career and I finally had a chance to make it right. Ironically, I am speaking to our dental students next month on Iatrogenic dentistry, so I have been putting the presentation together, and this case will be in it. This patient presented in early 2013 for a crown on #8 due to a "dark tooth" after some trauma he had several years earlier. He also had some old bonding on 9 but he wanted that left alone as he had it replaced multiple times before and it was now stable. I was just starting to play around with anteriors with CEREC, and obviously I had a lot to learn. I took a quick shade, decided A-2 seemed to match, and we went forward with an Empress Multi block in A-2. I still love Empress Multi for anteriors, but when I first started using it I was almost trying to force fit it into situations where maybe it wasn't appropriate. At the time, the patient was very happy as his tooth had been pretty dark and so he was happy just to have a significant change. Once I heard he was happy, I couldn't bond it in fast enough! When I saw him for a follow-up, he was still happy, but I could tell that I clearly had missed...I discussed with him trying to replace it but he didn't feel there was any reason to.
Fast forward to this week, and he is unfortunately getting divorced, which is causing him to re-assess everything. He mentioned that in pictures he noticed his tooth looked dark, and he was wondering if I would still be willing and able to replace the crown. Of course, considering I always hated his crown more than he did, I was happy to oblige...these patients are our advertisements to the world, so I would much rather have him looking as good as possible. The lessons learned here and in Scottsdale gave me a totally different way to assess the case and think about the final restoration, especially with regards to material choice and focusing on the value, texture, etc. So, we removed his existing crown, refined the preparation, and fabricated a new crown in e.max A-1 MT and bonded it in place using VarioLink Esthetic Light:
While it isn't perfect, and looking at the pictures I may need to adjust the length slightly when he comes in for a follow-up, this is obviously a much more acceptable result...hopefully this helps his confidence as he moves into the next phase of his life. I was only out a little time and the cost of materials, which is a small price to pay to be able to sleep at night knowing that I have done right by my patient. Now if I could get him to let me replace that bonding...
The real takeaway is to focus on value and texture, especially when it comes to anteriors...if you haven't taken Level 4, it is an amazing course that can really help out with these aspects. And if something isn't up to your standards, don't be afraid to make it right. We have such an advantage in being able to control the cost and the outcomes we obtain, so take advantage of it! Your patients will appreciate it, your team will have more respect for you, and you will feel better about your practice as well.
Last Thursday, as I was getting ready to close down my day and meet some friends for dinner, a new patient called up and said he broke his porcelain crown. So, we told him to head on over, assuming I would just patch him with composite or tell him to be careful over the weekend and that we would address it the next week. At first glance it looked like he just had a crack line on the facial of #9...the gingival inflammation could have been a clue that there was some movement of the restoration, as he reported that wasn't always there:
No big deal, right? Well, I touched it with an explorer and the entire crown crumbled off of the tooth...and now it is my problem. Sweet...so, looks like my Gibson's bone-in ribeye will have to wait(worth the trip if you come up to Chicago, FYI). How would we have handled this before CEREC? Try to free-hand a temporary, maybe slap a bunch of composite on there to get him through the weekend? Well, this new patient was thrilled when I told him that we could get his new crown completed right then if he was willing to stick around for a bit. So, cleaned up the preparation-the previous dentist did a nice job of keeping the lingual portion of the preparation above the cingulum, so there was still plenty of tooth structure.
The software spit out a nice proposal that only required a few minor modifications:
The lessons learned from this site and Level 4 in Scottsdale have really helped me when it comes to both composite bonding and my anterior CEREC restorations...just thinking about things differently has made a huge difference for me and my patients. I ended up restoring the case using e.max A-1 MT as he had already fractured one anterior crown and clearance was a little tight on the lingual. Added some texture and a little white to the line angles to give the restoration some added life, and then bonded in place using VarioLink Esthetic Warm:
I am looking forward to seeing how the gingiva responds when he comes in for hygiene, but it was certainly nice to be able to help him out...he was blown away by the technology and the fact that we were able to solve this big problem for him on the spot.
I know we all get frustrated and focus on what else we wish this technology could do for us, but this case really reminded me how fortunate we should be for the things we already can do. This would have taken a ton of work to get an even remotely acceptable result, but instead I was able to use CEREC to impress a new patient and get myself out of a jam. The steak was fantastic, by the way...medium rare, mushrooms on the side...just want to make sure I give all the information-sorry, forgot to take a picture of that!
Just thought I would share a case I completed on Friday where I previously succumbed to the definition of insanity-doing the same thing over and over and expecting a different result! Patient is a 46 year old male(neighbor of mine) who has a clear history of bruxism and has had his lateral incisors bonded many times(including by me) over the years. Here is how he presented:
Now, the last couple of times I really tried to make sure there was no pressure on the laterals...we have had discussions about a more comprehensive treatment plan but that is not really in the cards for him at this time. He was looking for a more definitive solution for the laterals, and I was trying to figure out why he keeps snapping his bonding off. Well, trying to think about things a little more thoroughly, I took a look at his maxillary canines and his lateral movements-here is what I saw:
Obviously, he has lost his canine guidance and has been whacking on the laterals, which has caused him to ruin any bonding he had done. I probably could have bonded this 100 more times and still had the same problems. So, we decided to try something I picked up at a composite course from Dr. Ron Jackson(great instructor, by the way), and restore the canine guidance with composite-now, this will likely wear back down over time, but we can monitor it at his recare appointments and "refresh" the composite as needed-and since an overhaul isn't a possibility right now, this is a nice compromise. So, we prepared 7 and 10 for all porcelain crowns, keeping the lingual margin above the cingulum to preserve as much tooth structure as possible, and built up the incisal edges of 6 and 11 with composite:
We restored 7 and 10 with e.max A-3 MT with some white at the mesial line angle(Kris:)) and a little sunset at the gingival...added some texture to try and get the appropriate light reflection. The patient was happy(as was I), and hopefully this gives him some stability in that area. I have had many frustrating cases over the years where I have bonded an anterior tooth only to have it get chipped a few months later...especially when I have stayed in the "single-tooth" mindset. Probably could have saved myself a lot of headaches just by thinking about things differently, as in this case...hopefully this helps someone else who has faced the same situation!
In previous posts, I have mentioned how much I love guided implant surgery. It takes a lot of the guess work out of the process, and also reduces the "pucker factor" associated with implant placement. When planned properly, it is generally a very smooth and seamless process, resulting in a good experience for the dentist and the patient. However, despite the fact we have planned everything in advance, we still need to remember to check along the way and make sure nothing has changed or gone wrong, including user error, which is what happened here! I have generally placed Camlog implants due to the ease of their guided system...however, in this case I decided to try Straumann, mainly because of the posts I have seen here and feedback I received from some friends of mine. I stayed away from the system because of the keys required, but I have to admit they were not nearly as big of a deal as I thought they would be.
Patient presented with tooth #4 fractured and unrestorable:
So, I extracted tooth #4 in July 2016 and grafted the site:
The patient opted to wait until last week to come in for implant placement...we planned a Straumann bone level tapered implant 4.1X8 to go right up to the sinus. Here she is prior to surgery:
With the guide in place I began my osteotomy...this is where I screwed up! Being used to Camlog, where you ordered one set of burs, and having this be my first surgery with Straumann, I didn't notice there is a guided bur with 1 line, 2 lines, or 3 lines, correlating to the different lengths:
Even though we are going with a guided surgical protocol, I still always take a check film along the way...thankfully, I grabbed the 1 line drill and not the one with 3 lines! As you can see, I was way short of my desired location(instead of into the sinus if I would have grabbed the other bur), so I had to step back and figure out what happened.
Obviously, this was me being a knucklehead and not an issue with the guide or the system. So, I switched to the 2 line bur that I was supposed to use, and finished my osteotomy, which left me ready for placement at the desired depth:
I placed the implant fully guided-I really liked the way the implant engaged the bone:
And then 1 final PA with the healing cap in place, showing the implant right up to the floor of the sinus where I had planned it:
The patient is aware of the need for a new restoration on #5...
So, keep in mind that although we have planned everything in advance, it is still wise to proceed cautiously and take periodic radiographs to ensure you are following the planned treatment. I have spoken with some dentists who don't take a radiograph until the implant is in if they are placing them guided...this case hopefully shows a good reason to take a check radiograph along the way and make sure you are on the right path, especially if you pull a bonehead move like I did. For the few seconds it takes, it can save you a lot of time and risk later on!
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!