Blog Author: Steven Hernandez
This patient was unhappy with the appearance of her teeth; crowns on teeth #8,9 were too wide, multiple stained/failing class V resins, and wear facets.
A wax-up was ordered, patient viewed it, approved the design.
Teeth were prepared, wax of design was transferred to the teeth. Occlusion checked/adjusted.
Patient was seen while in temporaries to check function and esthetics. She requested changes as they appeared "too masculine." Incisal edges were rounded and embrasures opened to soften/feminize the teeth. Eight Empress restorations were milled and hand-polished; no glaze. Final photograph is three months post-delivery.
1. Start with a wax up.
2. Use reduction guides to ensure that you remove enough tooth structure
3. Have the patient 'test drive' the provisionals; use this time to evaluate esthetics and function.
4. Once the patient is happy, simply copy what's there. All the guesswork is removed from it.
5. Don't be afraid of using CEREC for anterior cases. Take the Level 4A hands-on workshop & see what's possible.
We all know CEREC is capable of producing great aesthetic results, makes restoring implants easier/faster, and can even mill surgical guides in office. For me, one of my favorite procedures is the same day root canal, build up, and crown. I know the clinical situation doesn’t always allow it, but when it does, I find that CEREC allows me to leverage my time for both the benefit of the patient and myself.
Last week, this patient appointed for an OB resin on tooth #30 and a root canal, build up, crown on tooth #31. The appointment was scheduled for 7 AM and the patient was out before 9. The appointment workflow looks something like this:
- Seat/numb patient (1 septo)
- Capture pre-op images of the opposing arch, BB, and mandibular arch.
- Use the cut tool to remove tooth #31.
- Deliver second carpule of anesthetic (septo)
- Place IsoDry.
- Prepare #31. I didn’t have to spend much time searching for the canals as the decay already involved in the pulp chamber. Also, reviewing my CBCT prior to treatment let me know exactly how many canals there were. As I know I’m doing a root canal, I don’t have to be timid about my occlusal reduction. As you can see, this is anything but a traditional prep. I would guess my prep took ~10 minutes. I don’t want to image with the pulp chamber opened, so I placed some packable resin and just took a few seconds to smooth it, simulating my core build-up (don't bond this into place).
- Capture CEREC images and pass the AC unit to my second assistant to design, mill, fire the restoration.
- Place rubber dam, remove resin in chamber, start RCT.
The RCT is relatively quick as I had already found my canals. Also, using my CBCT to estimate canal length and an M4 handpiece making getting to length relatively easy. The crown is usually out of the oven when I’m finished and is ready for try-in. I always seat the crown and let the patient see what it looks like to get their approval. After that, it’s prepared for bonding. The IsoDry is placed again in the crown is bonded in place. The resin on #30 can be completed at any time; before CEREC images, after bonding crown, etc.
The power of certain comes into play in that the crown preparation is completed prior to the RCT. If I find that I can’t get the canals dry or I need a second appointment to complete the RCT for whatever reason, I will usually mill an MZ 100 and bond that in the interim.
So we had a patient arrived today as he heard weeded we did the same day crowns. He presented with some severe perio & class III mobility on tooth number 10. Patient stated that he is a teacher, goes back to work tomorrow and couldn't as he was. The tooth literally waved in the wind as he spoke to me. Yes, he was informed of his perio condition and the need to return for a full, comprehensive exam but he wanted his chief complaint address today. Here's his PA:
Solid as a rock.
We took a bio copy image of the tooth, extracted # 10 and imaged the site. I milled out a CeraSmart A1 and stained the cervical using my Cosmedent kit. I’ve seen a few cases completed by Kristine Aadland and I attempted to follow her lead; I failed. However, the patient was thrilled.
The restoration was delivered using Variolink DC and the patient left with an appointment for a full, comprehensive exam. With the neglect I observed in his mouth, I’ll be surprised if he returns. One can hope. The point of my rambling is this: we have amazing technology at our fingertips. No way I could work this into an already busy schedule without CEREC. Even after 10 years, this technology still amazes me.
Happens all the time. You complete a single-central and feel you've done a great job. Then, as many others on here do, you photograph your stellar work only to find that your "A" is more like a C+. Statements such as, "The patient was thrilled..." can be found all throughout this site. And while that's important, we (I feel I can speak for many here) know it's not the only factor...nor is it the most important. Here are 2 such cases where 'the patient was thrilled' but my efforts were less than ideal. Hopefully you'll see something that can help you in your next case and avoid these pitfalls.
Gentleman fractures #9, implant placed. The surgery isn't the point of this post, so we'll skip to the restorative portion.
Healing abutment. I've set myself up for success. Now I just have to not F it up.
Notice how 'bulbous' the restoration is? Way too round. I didn't take my time and contour in the mouth before delivering. Incisal edge has no characterization and the distal incisal edge is too short.
Again, he's happy with it but with minor corrections, this case could have turned out much better.
PFM #8. Pt not happy with appearance.
What I found as soon as I removed the crown. Prepare tooth, blockout with Cosmedent Pink Opaque.
Shade, texture are ok but the distal line angle/incisal edge are too short. Also, I could have closed the incisal embrasure a bit more btwn #8/9. I also missed the incisal translucency present on #9; could have been corrected with some blue on the lingual of the restoration.
Overall, small items...but items that were missed/are lacking nonetheless. Thanks to those who post cases from which I have learned a lot...my hope is that I can do the same for someone else. And if you haven't, make your way to AZ or NC for hands-on courses...you will cover this in depth.
Enjoy the Holiday weekend!!!
Nothing fancy here. Typical case. Pt appointed for #2, #3, #15 direct resins and #5 crown. We scheduled 2 hrs and finished ahead of time; just over 1:30 (#5 Empress polish only; no oven time). I hope the following tips help you leverage your CEREC and complete more treatment in the same amount of time.
1. Anesthesia of upper right quad only. Next capture pre-op images of arch as I wanted to copy the B cusp of #5. Also image opposing arch.
2. Teeth #2,3 & 5 prepared. *Note that I did not spend time restoring the molars. As soon as the images were captured and we advanced to the model screen, anesthesia was delivered for #15.
3. You can use pre-op images to check your reduction if you're not using reduction burs or bite tabs.
4. Copy line of #5 that avoids the DO resin, hole in the occlusal surface & abfraction.
5. Initial proposal.
6. Overlaying images of pre-op and CEREC proposal.
7. Final design of #5 with unrestored #2,3.
*While the CEREC was moving from AQUISITION to MODEL phase, anesthesia was delivered for #15. No 'downtime' waiting for CEREC to process models.
*While #5 was milling, #2, 3 were restored and #15 was prepared for a direct resin (OL).
*Leaving #2,3 unrestored during imaging of #5 allowed me to disregard them when designing occlusal contact strength of #5 crown.
*After restoring the molars, I could adjust the occlusion of #2,3 while #5 was milling. Without the crown in place, I could disregard occlusion of #5 prep as there was none.
*After delivering #5 and cleaning the area, #15 was restored. As the upper right had already been restored/contacts adjusted and polished, I only had to concentrate on #15 when adjusting the composite.
Again, this isn't 'sexy,' just everyday bread and butter dentistry. My hope is that you'll find all the little areas of 'downtime' during a crown appt and find that there is plenty of time to complete other dentistry and make the appointment more productive while not increasing chair time.
Yes, it's true. Love seeing something like this on the schedule; 18-MO, 19-MOD, 20-MOD, 21-DO. Why? CEREC. Prior to having my CEREC system, a quadrant of CL II direct composites was not cause for celebration. Why? Because I would be tied-down to one operatory, start-to-finish, unable to do another/more profitable (and fun!) procedure. Sorry, but tinkering with matrix bands, wedges and clamps doesn't excite me. And sometimes, despite my best efforts, I'd remove a matrix band and find a void or open contact or...
With CEREC, my attitude (and how I approach the case) has completely changed. Let's look at a recent case:
Carmen presented with failing amalgams and interproximal decay in the LLQ; #18-MO, 20-MOD, 21-DO
My workflow with CEREC is fast, predicable and results in better restorations that I can provide by hand. In this case, I designated #18 & 20 as BIOCOPY restorations using the 3M MZ100 blocks. These blocks are resin, not porcelain. And unlike a composite that I place in my office, these are already polymerized; no shrinkage. The result, better fit and longer lasting.
I delivered anesthesia and captured BIOCOPY images.
I prepared both #18 and #20...initial designs.
Only small changes were required before both designs were complete. To leverage my time while the restorations were milling, I prepared #21. Once #18 & #20 were seated, I built the contact against #20.
1. Don't forget about the MZ100 blocks. I find them useful for fillings, tempoary crowns, etc.
2. If you have an EDDA and your state allows it, have them mill/deliver the restorations.
3. CEREC allows you to leverage your time. While the restorations are being designed/milled, you're free to perform other dentistry.
This past Jan, we had a new patient walk into our office. She was distraught over a broken front tooth. I met her and saw an existing Cantilever bridge from #6-7 with #7 completely missing.
She still had possession of the pontic and stated being happy with the shape/contour/esthetics of the previous restoration. Tooth #7 was placed in the mouth and BIOCOPY images captured.
Anesthetic. Preparation of #6 was completed. Images captured.
Final Design with BIOCOPY images confirmed a precise copy of her previous restoration.
The only alteration of the design was on the palatal surface of #7; occlusion/protrusive contacts with the opposing arch lead to failure (see arrow)
Immediate delivery pic
The pt was so happy that she took time out of her busy day to write this wonderful review. Again, without CEREC, this final tx option wouldn't have been possible. To date, she has referred 2 other pts to our practice. These are the pts that you know will be with you for life. They will be raving fans and ambassadors for your practice.
Pt contacted the office today at 2pm and reported a broken front tooth. Crown and RCT completed years ago, not by me. Occlusion was evaluated and, with the remaining tooth structure, I felt enough ferrule could be gained to place a post/core, crown. At 78 years old, her main concern was church tonight and how she couldn't bear to be seen (it's Wed in the South, ya'll). With the hx of RCT, no anesthetic was necessary. Cord packed, post/core, prep. CEREC images. Design, mill Empress A2 Multi. Bond in with RelyX Ultimate. I know immediate before/after pics aren't the best for presentations, but I think in this case it highlights the power of what we can do. While I love implants and guided surgeries, having the ability to replace a front tooth in under 2 hours still blows my mind after 7 years with CEREC. It may not be guided surgery or printing sexy/cool, but it's bread and butter dentistry that pt's truly appreciate.
Female patient with existing bridge from #7-10; 8 and 9 are the pontics. She's not happy with the esthetics and won't even smile fully due to how bad it looks. No worries...I have CEREC. She's not interested in implants and I'm not comfortable using laterals as abutments. So, we decide to do 2 bridges; #6-8 and #9-11 (cantilevers). She was anxious to begin so Mr Know-it-All here didn't feel a wax-up was needed b/c I could knock it out of the park. Let the scanning begin!
So CEREC images are taken. In the ADMIN screen, I designate #6, 7 as crowns and #8 as a pontic. I then designate #11, 10 as crowns as #9 as a pontic. HERE'S WHERE I SCREWED UP. I did not notice that the computer thought I was designing a 6-unit bridge and not 2, 3-unit bridges. Notice how all 6 teeth are connected? Yeah...I missed that.
I finish my design and finally notice the problem. Oh crap. I went back to the ADMIN screen and attempted to change it. Nope...not permitted. If I re-designated the teeth, I lost the design. I solved my problem by creating a space/gap between the centrals. How? Dial in the contacts to where you want. SAVE the case. Use SHAPE ANATOMICAL tool to move one central and create a gap. Mill that bridge. Close the case WITHOUT saving it and you open it back up with the centrals/contact perfect again. Use the shape tool on the other tooth and mill that bridge.
Yes, it wasn't fun adjusting the contacts and shaping the bridges but I made it work. Here's the mistake I made and how to avoid it
Note the arrow and how the computer has all the teeth connected. Click on the chain and remove it to designate the case as 2 separate bridges.
Hope that helps someone avoid the fun I had milling these (each took an hour) and adjusting the contacts. Yes, I could have redesigned the case but I also wanted to see if my work around worked. Here are the immediate delivery pics.
cerecdoctors.com Mentor Dr. Steven Hernandez shared this case on the Discussion Boards:
I remember a day when I used to either send the partial to the lab or use some sort of material and hope to capture the contours of the clasps. No more. With CEREC, what was once hard is now easy. This patient fractured his previous crown; nothing worth saving/imaging for Biocopy. Workflow...
1. Capture bite
2. Image top arch
3. Prep tooth
4. Image tooth
5. Add gingival mask folder, seat partial, image with partial in place
If you want to learn more about this case visit https://www.cerecdoctors.com/discussion-boards/view/id/36042