Blog Author: Daniel Wilson
I'm sure many feel like anteriors can be a labor of love, especially handling single centrals. I never feel like I charge enough for some of these cases. Here's a case I completed today. This was a college student who was heading back to school on Sunday and his family wanted me to complete his case before he headed back. He had some trauma to #9 about 7 years ago and had it repaired by his pediatric dentist. He also plays the clarinet competitively as well and the asymmetry between #8 and 9 was causing him some frustrations with his mouthpiece. Because of his scholarship for music, he had zero interest in orthodontics.
So when I see cases like this, I'm trying to plan the case before I touch the tooth with a bur. Mike, Sam and Flem really do a great job of getting you to develop a gameplan before you tackle these cases in Level 4. Prep design, Facial reduction, core color, occlusion, block selection, characterization, etc...
As you can see, the VITA Classic Shade of A1 is close in color to the adjacent tooth #8. I choose IPS Empress CAD Multi for this case and even though Empress to me tends to be a little brighter, I chose a B1 Multi block for this case. I know that with less facial reduction and the goal of trying to preserve enamel, I will get a value drop on these cases. Your facial thickness of porcelain is critical to take into account on all of these cases. If you ignore it, you can get burned quickly, ask me how I know.
The preps look aggressive but the facial reduction is minimal 0.5-0.7mm. I almost always break contacts and I try to have smooth, rounded margins to help allow the restorations to drop into place and have a great fit with CEREC. This case was stained and glazed with Empress Stain and Glazes and fired on P4. I missed the texture a little on this case and width could have been better as well. Overall, I would call the case a success with a happy young man and family before he heads off to college.
I received a sample of Ivoclar Vivadent's Tetric CAD. This was a case that I thought would be more of an onlay and my mind was dead set on using the block. In my humble opinion this block is perfect for inlays and onlays. The tooth's condition dedicated my prep and with the presence of distal decay that wasn't apparent on the radiograph and with the small buccal breakdown, I changed gears and went with a crownlay prep. In the past, I would typically use IPS e.max HT or MT for these crownlay indications.
Tetric CAD is in the category of hybrid ceramics. It has great edge stability during milling, polishes easily and doesn't have to be fired. With a flexural strength of 272 MPa, it is higher than the other hybrids. I bonded this restoration with Ivoclar Vivadent's Variolink Esthetic DC Warm cement under rubber dam isolation. I have attached a CEREC Materials spreadsheet that I posted earlier this month for those that would like to see the different materials and their properties and indications.
This appointment was less than an hour from start to finish. Polished only. Despite the fact that the value is a bit high occlusally, it still blends beautifully around the margins.
I know there is a lot of discussion about what materials to use in the anterior zone. I don't think there is necessarily a universal answer but what I've learned over the years is to understand the properties of these materials and their strengths and weaknesses.
In general, I'm trying to use Feldspathic porcelain (VITABLOCS typically for me Mark II or TriLuxe) or Leucite Re-inforced Glass Ceramics (IPS Empress) in the anterior region. I feel like they have more vitality, given the right case, you can just mill polish and cement and get a really nice result. This is a case with VITA TriLuxe 1M2 polish only
I know the go-to block when using e.max in the anterior region is e.max MT. I really like the block and use it quite often as well. My point for this discussion is that a lot of doctors will shy away from e.max HT. There is the big fear of the dreaded "grey" crown or a crown that has "low" value. It is a real concern. I've had it happen to me and if you aren't careful, it can happen quite easily. This was my first case I posted on CEREC doctors and at the time I thought it was quite good. Now I would have approached it differently because of the "low" value of #8,9.
This case I did about a year ago. It's not perfect but it is a vast improvement over what she started with. She is quite happy, but I always evaluate my photos and have other CEREC doctors look at them and give me their feedback. Dr. Tom Monahan and I share cases back and forth, and aren't afraid to pick apart our cases. It makes us better and I would encourage you to do the same.
So I chose HT for this case because I felt like I did see some C-tones in this case. I felt like MT would be too bright or high in value for this and I didn't feel great about using Feldspathic on this case because of limited space on the lingual. So I used A1 HT. I compensated about 2 shades in order to offset the drop in value. I wish I would have taken a pre-op pic with a shade tab but she was closer to A3.
There are a lot of ways to approach these anterior cases, but I felt like e.max HT was the best solution and what I saw for the case in my eyes.
This was a patient who arrived at my office after a less than optimum orthodontic finish and failed hard and soft tissue grafts for the area of #8. I encouraged her to see my periodontist that I work with, but she was "tired and done". She couldn't stand her essix and wanted a bridge. I talked her out of it and said that we could do something as a long term temporary and then when she was ready, we could explore grafting and implants in the future. I bonded #7 to correct the mesial concavity. #9 was used as the retainer. I did prep slightly on the lingual of #9, but still kept the prep in enamel to maximize the bond for the restoration.
This was a 2 hour case. I stained and glazed in the mouth but still needed to do a second fire to get it to my satisfaction. I used IPS e.max A1 LT.
This isn't a novel post but for some of the new CEREC users, I thought I would share some bread and butter dentistry. I would rarely do crownlays during the BC (Before CEREC) days. As we all know the biggest challenge was provisionalization and you as the clinician had to be knowledgeable enough about materials to explain to the lab technician about material selection, color and translucency so you could get the results you desired.
Now with CEREC, there are a number of different materials at our disposal and no worries about provisionals. For this case, I had plenty of enamel to bond to and enough clearance so I could have used just about anything in this case. Typically my go-to for crownlays is IPS e.max HT (high translucency). I've used MT with success but I find blending the margins is a bit easier with HT.
Another thing I really try to focus on with these cases is smooth flowing margins. Unlike the days of gold inlays and onlays where sharp internal line angles and boxes were the norm, resistance and retention form are not my primary concern. With proper bonding, these do not come off.
For this case, I intentionally choose A2 HT because the cusp tips of the premolars where brighter. I selectively etched the enamel with 35% phosphoric acid, scrubbed the tooth with Adhese Universal for 20 seconds and bonded with Ivoclar Vivadent Variolink Esthetic Warm Plus.
Nothing earth shattering, but these are the types of cases where efficiency and predicatability are paramount for us each day.
CEREC gives us a ton of options and allows us to do treatment for patients without the frustration to us as clinicians or frustration to our patients. For me one of those treatments is Maryland Bridges. As we all know, if we attempt to do this with a lab, provisionalization is challenging and we are at the mercy of the lab for getting the shade and fit correct. CADCAM has made this a very efficient and predictable option for us chairside.
This patient has a lot of compromises but really wanted something fixed versus her removable partial to replace #23. As you can see from the radiograph, tooth #24 is not doing well. I had her get a consultation from an endodontist and took a CBCT. He thinks it looks fine and would be a candidate for an abutment but I still think the tooth is toast. I really wanted to avoid potentially opening a bag of worms with #24 and didn't want to prep #22 for full coverage to act as an abutment for a conventional 3 unit FPD.
So after some discussion, I felt a Maryland bridge was the best option. In this case, I did prep a little into the canine a little bit.
Here's the proposal:
Restoration at try-in:
I used a C14 block A2 LT. I did have to re-fire this case a second time for color.
Nothing earth shattering for this case, but I'm still amazed how we can do this in less than a two hour appointment and be ultra conservative and get a great result. I don't know how long this will last (I've been searching on PubMed for articles that Skramy refers to but couldn't find them), but with total etch and enamel bond, I think it will do well for quite some time.
So my patient coordinator says her step mom is in need of a second opinion about her front tooth. I tell her to send her over and sure enough, she has a old, loose PFM that is failing and there is inadequate ferrule and simply has a poor long term prognosis.
She is mortified about esthetics and how this implant will look (despite her many other dental concerns). I don't place implants yet, but walk her through the process and give her the recommendation for the surgeon I work with, etc., etc. Fast forward to about 16 months ago, she shows up at my office saying the surgeon says she is ready to go. I'm a bit lost now because I hadn't heard anything from my surgeon and our plan was to make her a custom healer at the time of surgery. Anyway, she ends up seeing a different surgeon in town, has extraction of #9 and immediate implant placement with a Straumann 4.8RC. Now fortunately, this isn't the end of the world in this case. Implant was placed pretty well, it is a tibase compatible system but there were some challenges that I had to deal with that took some extra time and extra cost (thankfully I have a CEREC otherwise the costs would have been even more). So here's a pic and radiograph of how she presented with the implant in place .
As you can see from the initial photo, I have some gingival asymmetry to address, so we discussed that I would be placing a provisional crown to help shape the tissue and make the final result more esthetic. She had a minor freak out moment until I explained that her provisional implant crown wasn't removable like her flipper :) So I choose to use Telio CAD as a provisional. For those of you that don't restore implants yet, I would highly recommend Level 3. This by itself has paid for my CEREC several times over. Plus, having full control of the outcome it nice too. I used to hate making an implant provisional chairside. It is time consuming and tedious. But with CEREC, this become quite easy and predictable. Yes, it cost me about $150 in parts for the variobase and for the TelioCAD block, but I'm still ahead even after the cement retained crown that will cost me a little less than $180.
As you can see from the radiograph, the implant is countersunk about 0.5-1.0mm. It may be a bit exaggerated from the angle of the PA. I was able to seat the scanpost completely, and then we designed Screw Retained Crown on the CEREC. Sorry I can't pull up my design right and show you a screenshot of it, but usually I make the facial emergence profile a little concave for everything touching the tissue with my anterior implant abutment or crown. In this case, I matched the shape of tooth #8 in my proposal at the gingival third so that I would get the tissue to move apically to my desired location. Everything above my depicted line was concave and not blanching the tissue. I will say I did have to make releasing incisions on the mesial and distal interproximally to get the tissue to release enough to seat provisional crown completely
One important step with using Telio CAD is that you need to use SR Connect on the intaglio surface of the implant crown. This is an methyl-methyacrylate(MMA) liquid that is light cured in order to optimize the bond of the Telio CAD to the tibase. Still sandblast the tibase, use your Monobond Plus and cement with the Hybrid Abutment HO cement by Ivoclar Vivadent. Sam has an excellent video showing the full process.
Here is the Telio CAD provisional seated about 1 month post. Not perfect but much better.
At this point, things are more predictable and easier to deal with. This wasn't an ideal case. The patient is in some serious need of soft tissue grafting in a number of areas. Wasn't interested in ortho and wouldn't let me recontour a few of her other teeth to help with some line angles, but overall given my restrictions, I was able to make her happy and deliver a nice result. This would have been a lot more unpredictable and expensive without CEREC.
Final restoration: (Photos are 15 months post op)
Utilized IPS e.max MO-2 abutment block (fired on P7)
IPS e.max B1 MT
This is a case I did on the 23rd of December. It was supposed to be a nice easy day just working and documenting this case but as you would expect, I had two emergencies that needed help so that made my day a little more chaotic. That being said, I share this case because I am hoping to stimulate some discussion. This isn't my favorite case and in retrospect I would have chosen a different block. I choose VITABLOCS TriLuxe Forte and ended up with A2C. I have my thoughts about what I would have done differently but I'm curious to hear how others may have approached it seeing the before, preps and after.
The patient and his family were really happy with the end result. However, I talk about as we all know, we grade anteriors on a different scale. I love doing them and the challenge but it definitely can be humbling and make you lose a little sleep when you critique your photos.
I just finished this case today. I know I posted about Feldspathic porcelain blocs but I just love the material. Here is a veneer that I did on #10. I used VITA Triluxe 1M2 and stained and glazed with Empress stain and glaze and fired on P4. Total etch, Adhese Universal bond and Variolink Esthetic Neutral.
There was a thread last week when Sam kept asking why not Feldspathic Porcelain for a Veneer or an anterior crown. For me personally, a lot of my decisions for block was a matter of very my comfort was, and not being familiar with the properties of other blocks. After going to Level 4 a few years ago, it was the first time I really saw Sam and Mike's affinity for VITA blocks. As we can all attest to, Mike's case make us want to cry sometimes because they are so good and makes me wonder what type of "hack shop" I run :)
Everyday I get better and better with understanding block selection for certain cases, but as I use VITA Mark II or VITA Triluxe more, I really like the esthetic properities of the materials and obviously being able to see color straight out of the mill is a huge benefit too.
Here are a few cases that I have done to showcase the power of the block. Obviously, VITA isn't the strongest material we have so if strength is a major concern for a cause, I would revert back to blocks like Celtra Duo or eMax.
This patient hated the spaces at the gingival 1/3rd of her lower anteriors. She is post ortho and I inherited the case after the ortho was already finished. We discussed the challenges of closing the spaces completely, and I wanted to prep them as conservative as possible but essentially they are crown preps because I had to prep interproximally to the lingual aspect so far to help with the space closure gingivally, and was only able to preserve the lingual cingulum of the lower teeth. Funny how pics show all your flaws, but I swear I rounded all the preps with a 3M finishing disc and they still look to sharp in a lot of areas. Fortunately, the restorations all milled and seated beautifully. This was a case I did same day. I have 1 mill unit and used Biojaw to help with the design of the crowns, and the patient was in the chair for about 4 hours.
Day of Pics:
1 month Post op:
Ironically I didn't stain and glaze the case. I tried the crowns in and polished them slightly but when I tried them in, she was so happy that she didn't want me to do a thing. So I polished them completely and bonded them using a total etch technique with Variolink Esthetic Neutral. The blocks were VITA Triluxe 1M2. I still am pretty amazed that we have materials that can come out of the mill, be polished and bonded and look like this.
Patient needed veneers on #8 and 9. Again I used VITA Triluxe (A1C) and bonded used total etch technique with Variolink Esthetic Neutral. This was one of my first cases with using GC Lustre Paste. I hate the texture. Part of the learning curve of using Lustre Paste. It really is apparent in the photos but the patient loved them so much that she didn't want me to touch them. One of these days I will find an excuse to polish this veneers more :)
Day of pic:
1 week post op: Sorry about the articulating paper mark...ugh
This was a really frustrating case. Patient hated her crown because of the dark grey margins and asked if I could improve it. I tried and failed with emax LT. Ended up sending her home and milled out a few different blocks and the one that looked the best was VITA Mark II A1. I did bond this with a Variolink Esthetic Light. This was stained and glazed with Lustre Paste. The whole reason I chose to even mill the crown in Mark II was because I was reading about a veneer case that Mike had done where he was able to conservatively prep for a veneer and block out a reasonably dark prep. So I thought, what the heck, I'll try it. Not perfect but the patient was pretty happy.
Color of core after PFM removed: