Blog Author: Kristine Aadland
This summer I had the opportunity to go to a women in leadership meeting held by Dentsply Sirona where I met some amazing and talented women. I have been working hard to get them to post their cases but it has been a little intimidating for them due to some previous experiences so I asked if I could share a few of the cases that get sent my way. It is intimidating to share work that you created yourself because you have to own it and often we pour our heart into our work. This is the only way though as a community we can elevate ourselves and other clinicians by sharing our work, encouraging other,s and offering constructive criticism when needed. It has been disheartening to see some of the bashing that happens online on some of the Facebook groups and that is why I am so proud of the community that we have all created with cerecdoctors.com.
Look at this work!!! I was blown away. Just to be clear- These are not my cases. I would be so proud to show them as my own, but I get no credit for this talent.
Case 1- e.max crowns #26 & 27
Case 2- Empress veneer #8
Let's show these talented doctors that posting your cases doesn't have to be scary. Show your support, and if you have feedback they are hungry for it, but just be kind in how you present it please ;)
I love to use Maryland bridges as long term temporary solutions. Especially when kids are getting out of ortho and not quite ready for implants. The most difficult part is typically the connector for these types of cases. A great tip I just got at CERECdoctors.com to help with this is to design the Maryland Bridge with the connector as an intersection, get the connector to about a 3, and then go back to admin phase and switch it to anatomic. This will help bump up the connector automatically to the needed size without the ridges that anatomic normally gives (I believe it is called the Fleming technique ;)). It was a great tip that helped speed up design. That is just one more reason why I love this group. Even coming to the courses to mentor, we can always get great tips!
Here are a few examples of some fun Maryland Bridge cases with kiddos. These can be done with the wing on the facial or the lingual and there are examples of both. This is dependant on the bite. What material I use is dependant on the amount of time and the amount of characterization that is needed. If the restoration needs to last less than a year, and I don't need to prep anything, then I love using GC Cerasmart. If the restoration needs to last several years, I have personally found that e.max tends to last longer. I do warn my patients and parents that these can fall off. It doesn't happen very often, but when it does it is only at the most in-opportune times. The good news, it's very easy to recement it and typically there is no damage done. They still love this solution much more than a flipper.
1. This is an interdisciplinary case with my orthodontist and periodontist. Her centrals were hopeless due to trauma but placing two implants next to each other can be really difficult to restore. We extracted #9, moved #10 into the #9 space and are holding on to #8 as long as we can until she is ready for implants (hopefully). She is 15 yrs old at this point.
2. Post ortho, a young man missing #9 due to trauma. He is 16yr old and still growing and could not stand having a flipper.
3. A young man congenitally missing #10 and also too young for an implant.
I decided to mill this instead of building it up by hand for this young woman. It milled in 6 min and then I added color tints and a thin layer of microfill of the top to seal in the color tints.
This was one of those cases that was just fun for me to do ;) I might have gone a little intense with my translucency stain but overall I think it blended pretty well. She was really excited to not have the dark tooth anymore. Just something a little different!
I don't get to do a lot of bleach shade cases in my neck of the woods so I am always a little surprised when I actually get the chance. Whew! They are bright and they are white!
Here is a woman who wanted some new crowns due to recurrent decay and she felt they were too yellow. My camera does not do the existing crowns justice. They were a B1!
Her concerns with her previous crowns:
1. #9 was longer than #8.
2. The incisal embrasures between the laterals and centrals were too open.
3. She also didn't like the "black pepper" look between her centrals. #8 and 9 had previous endo.
4. Her crowns were too yellow and she wanted to match her "new crowns" on upper right.
5. Her crowns were all different opacities- #8 & 9 were lava crowns, where as the others were e.max done at different times.
Her plan is replace her lower anteriors next year as well as her upper left crowns.
Here is what I love about my CEREC. This case was pretty easy because all of the hard work was already done for me. I could have done this either Biocopy or Biogeneric Individual. Personally, I chose Biogeneric Individual purely because doing the copy line is an extra step and takes more time. I do however add the Biogcopy folder in the acquisition stage, and scan the existing crowns so that I can use this as a reference point for midline and incisal length. I also have my checklist of things she didn't like and can correct that by ghosting the Biocopy model over my proposals. She did not want a lot of characterization in this case as far as staining, because she wanted Hollywood white. My rule of thumb on this is, the less staining the more contouring. It's how I can get them to pop.
This is a case I chose to do same day. Why? Because seeing one patient vs. 15 is very calming to me personally, and also because when I leave my office, I don't have time to come back and do lab work. The one visit is my scheduled lab time. This is also how I market my practice and I am comfortable with that. My husband does cases like this in two visits because for him sitting with one patient is the exact opposite of calm. He would much rather do this on his own time with no pressure of time. Is there a right way? Yes, of course- It is always the wife's way!!! (just kidding- the right way is whatever you are comfortable with!)
The new crowns are e.max BL 2 MT crowns. I needed a touch of opacity to block out the RCT on #8 and #9.
Late night CERECing thoughts...
It's very humbling to look back on cases when I started using CEREC 12 years ago. I was so happy to take a crown straight out of the mill and put it in the patients mouth. I had no idea what I was looking for when I looked at a tooth, other than if the color was right (which really meant was it close but not perfect). Today, I look at teeth in an entirely different way. I love to see the color patterns, the anatomy, the contouring and the light reflections. I am able to see this now because I posted cases and other doctors were willing to show me how to improve. I was also willing to accept those answers. That is what I love about this forum. We are all here to grow.
So what do I see in a case like this...
Anatomy of a youthful tooth: sharp line angles, prominent central lobe and contouring at the gingival embrasures on the mesial and distal. This is contouring that is done post mill.
Fun color patterns: the white bands at the gingival 1/3, the blue translucency and the white framing along the incisal edge.
Reflections: Do my reflections mirror each other? If so, then my anatomy is similar. If not, I need to re-contour to get them to match.
and the final...
Don't you just love that we have this capability in our office? So.dang.cool.
Here is a woman that came in with an old PFM that had recurrent decay but she was nervous to replace it because she didn't want the new one to "stick out". These are the cases I love!!
One tip that I like to do is mix my stains to get the color I want to achieve. This is a great example of that. She is pretty bright overall with a lot of translucency. Normally when I use brighter shades like B1 I would use "I 1" (the blue stain) to mimic the translucency, but in her case blue was just too bright- so I mixed it with the "I 2" (the grey stain) to tone it down but still give it some richness in color. I did the same thing for the body stain as well. The "1" stain (A range) was just a little too strong, so I mixed it with "creme" to tone it down. This only takes a few extra seconds but it gives you a huge palate of colors if you are willing to mix them.
The second tip that I have learned from others on this site is to look at the case from different exposures. I just wanted to show that in this example with the two different pictures- immediate seat and follow up. Looking at the different exposures can really help see the color in the tooth in more distinction. To do this with my twin flash, I take one picture with my flashes all the way tilted back and take a second photo with my flashes all the way tilted forward. Some of this will depend on the light in the room as well, but this is just a fast way for me to look at the teeth in different light. You can also do this on a lot of apps- like the photo app on your iphone.
What do I do when I am done with these cases? I look at my photos and see what I would have done to change it. I do this with my assistant, never in front of a patient. This is how we all learn to be better and hopefully improve with each case. Posting cases are also a great way for all of us to improve. That is the value of cerecdoctors!
Here is what I would have done differently:
I would have added either a little bit of glaze to the mesial incisal corner to sharpen it, or contoured #8 to match. This is an area that drives me nuts. If you use the smooth tool at all in the area it will round the mesial incisal edge and this is what you will get. I try to over close this area prior to mill just for this reason, but I got a little carried away here in my contouring.
I would have used "creme" for the craze lines instead of white. In the mouth this doesn't show up as dramatic but my camera never lies. Using creme would have been more subtle and matched her other teeth better.
One tip that I picked up from some cases here on the boards- add the body stain at the incisal edge of worn looking teeth. Often if you look at anterior teeth there is a lot of color right at the incisal edge- dentin showing through with the wear. I love to add a little of the same color I used at the gingival 1/3 here to mimick the other teeth.
What was cool about this case- The patient was in my chair for 2 hours and left with a new crown that she loved. That is the power of CEREC that we have available to us every day.
Here is just a routine crown on #14. What I love is that adding a tiny bit of customization literally took less than 2 min and it can make such a difference...
e.max crown, A2 HT. I chose HT because she already has natural grey showing through and I don't stock C shades. Add a little white for the decalcification marks- in no pattern at all and viola! This is so simple and can have a really great effect.
Here is a young woman, early 20s, that came in and wanted a bigger, brighter smile. She was asking for porcelain veneers.
I was hesitant to put veneers on her because she is so young and I didn't want to cut down her teeth if I didn't have to. She was already a B1 and had a great smile but this is someone who wanted Hollywood bright. I talked her into letting me do composite work instead. These I did free hand and I am so thankful for everything I have learned by using my CEREC that I could apply here. Could I have milled these? Probably, but the reason I didn't is because her contacts were so tight already that I thought I would be fighting seating these as a no prep, ultra thin veneer. If she would have had open contacts or even lighter contacts milling would have been an easier option. If I was going to mill them I probably would have used Enamic. They have the brightest shades available at this time as a hybrid. Instead I used Cosmedent Nano Plus composite, B zero. This is my favorite composite because of the opaqueness of it to give that bright look. I added composite on teeth #3-14.
She was happy when we were done, and I was happy that no tooth structure taken away. It was a win-win for us both ;)
Not too long ago my "CEREC assistant" moved to sunny California. I was happy for her on a personal level, but sad to see her go. She had worked with me for 8 years and she blossomed in her CEREC knowledge and training. Now I have had to refocus on training my other assistants and so I decided to make some easy flow charts for my lab to help out. If these can help anyone here than feel free to use them! PDF versions are printable.
Here is a tough implant case that walked through my door a few days ago for impressions. He was referred to me by the oral surgeon, post placement.
This is a young man who has never had a filling, but had got into an unfortunate accident with the handlebars of his bike and the bike obviously won. He went through root canal therapy on #9 and #10, crowns, retreatments, extractions and finally implants. He was ready to be done and have teeth and the surgeon told him I could do it in a day .
So this is what I see...
1. two implants next to each other in the anterior that are not easy to restore
2. Not awesome tissue or chance for a great papillae between #9 and #10
3. Distal inclination of #8 and an overlap of #7/8
I have the discussion with the patient:
Do you want ortho to straighten up your central?- "no"
Do you want to add composite on that tooth to make it appear straight?- "not really "
Did you have a gap between your front teeth before or a space?- "no, I want them to touch"
Would you be interested in another gum graft if possible?- "I really just want teeth that don't come out at night"
So here is what I came up with. I could not split this case because there was not enough room unless I put the margins on the abutments up pretty far above the gingival level. These are screw retained.
I was pretty excited about the staining and glazing. I used an A1 LT and carried the shade 1 down towards the incisal to match his other teeth. Here is what I am struggling with:
I don't love the midline slanting and wish I would have just placed composite there instead. The reflection on #9 tells me that I need to flatten that part of the facial wall just slightly and polish it back up to mirror the other central. Last but not least, I don't love the embrasure space between #9 and #10 but I am not sure if that is possible to fix.
Would a graft work here? Pink porcelain might have been an option for an illusion but super tricky, especially without a model. The other option I am thinking of is Anaxdent Anaxgum paste. I have never used it but saw it on another post... Has anyone tried it?
I am hoping to accomplish this:
but how possible is that?
At the end of the day he was happy to have teeth. I am just curious on what other people would have done in this case. I don't think temporaries would have done too much because there isn't a lot of tissue to move around. The implants are shallow. I'm leaning towards trying the anaxgum because I wouldn't have to remove or refire the implant crowns but I would love other ideas too.