Blog Author: Mike Skramstad
Those of you that were at my lecture in Vegas at DSW 2017 saw me do some bigger cases digitally. I thought I would post a case that I just finished that shows this workflow
I have seen this patient for some time and she has always told me that she does not like her teeth. She is mostly unhappy with 3 things:
- The lines and discolorations in her teeth
- The shape of her teeth (specifically #7)
- Tooth #9 was more facial than tooth #8
- The open incisal embrasures between the canines and the laterals
- The minor collapse of the buccal corridor
- The unesthetic crowns on #3 and #14 (recession and margins that showed)
To give you an idea what she was seeing, here is her smile:
I knew that we didn't need to change a lot...She had a very normal tooth display at lip at rest for a 46 year old woman:
I think it's important to REALLY talk to the patient about what they want so you are clear when designing the case. She made several requests including the following:
- She wanted her concerns fixed, but didn't want people to know that she had fake teeth. This meant a very natural shape that almost mimicked what she had now... just chaning the shape and buccal corridor a little bit
- She didn't like the "blue" at the edges... which means I have to watch the incisal effects
- She wanted a natural shade... nothing bright. More natural
So I took this information and scanned her with the Ortho software. I exported the scan to my lab technicial Bill Marais and he digitally designed the smile via Exocad. Now often times I will have him send me the case via .stl and I will 3D print the case and use as Biocopy. In this case we did more of a "hybrid" approach in which he "milled" the digital waxup on a 5 axis mill with a grey "puck" and then used his hand skills to define certain areas. We did this because I wanted details and it's difficult to get this kind of detail via 3D printing.
Next we duplicated in white stone just in case... I use this to make a Copyplast matrix for a reduction guide, to transfer the waxup to the mouth for depth reductions, and also to fabricate provisionals.
We went ahead and prepped the teeth. We made the decision based on the waxup to prepare more of a full coverage veneer type prep. We tried to keep everything in enamel as best we could due to this prep style. We prepped a little more based on the decision to move the teeth slightly lingual in the anterior. This also helped us control the function:
Tissue control is very important. I don't like dealing with inflammed gingiva so one tip is to make sure you pack cord prior to defining the margins so you protect the gingiva:
IMO, it's very important to get the waxup model to stitch with the prepped teeth. This makes a MAJOR difference in how easy the design is and how much closer it will replicate what you are trying to execute. For this reason, we left the molars intact (no waxup on these teeth either) and use them as stitching abutments to correctly overlay the waxup to the preps:
By doing that, here are our designs.. initial proposals took very very minor tweaking (only about 5 minutes)
I went ahead and exported the .stl of the preps and 3D printed a prep model. It was a solid model so I manually ditched the margins with a bur to get the restorations to seat. Here are the e.max restorations milled in EF mill (Extra Fine for better trueness):
I did some small incisal effects with Ivoclar Ivocolor and then polished the restorations (no glaze). Here they are ready for delivery:
And here are the final restorations bonded into place with Variolink Esthetic warm. She was very happy with the result. I think I could have maybe done a little more contouring (some washed out in the picture)... but shape is always the most important thing and we did what she asked... creating more of a monolithic tooth with a natural shape and natural color:
I have done very few bridges in the last few year...but sometimes you have to. This patient came to me with a ton of pain on a tooth that he said was extracted 8 years ago. After I took the PA we noticed the problem... an infected root tip that was left. He has been wearing a flipper.
He initially wanted to do an implant, but after flapping and extracting the infected root, we realized that extensive bone grafting was going to be necessary and it just wasn't in his budget.... so we did a bridge today (about 8 weeks after extraction). The bridge was e.max A3.
He was quite happy. This is immediate post op today... An implant would have been nice, but some scenarios a bridge does the job.
Prepping a full upper arch next week and just wanted to post this amazing waxup I got from Bill.... He always amazes me. It is expensive at $85/unit... but totally worth it!
Bill digitally waxes up in Exocad and prints it in an Acrylic puck... then after mill does hand touching and adjustments:
He then duplicates in white stone in case you would like to show to patient
Includes a great stent to transfer to the mouth if needed or for provisionals.... and a prep guide:
Here is a case I did on my wife's cousin. She had a trauma a few years ago that resulted in the tooth darkening quite a bit. We did the endo and tried internally bleaching twice and it was not successful. We decided to do a single unit veneer to correct both the dark color and the minor rotation.
The case was done in Biogeneric and the material was Vita Mk II 1M1 with stain and glaze.
Was just going through tons of pictures tonight and this is a case I finished a couple weeks ago. I don't do many bridges, but you have have to love the workflow when you do them.
- Prep Abutment teeth
- Image preps and root
- Mill Teliocad Temp and extract root while milling
- Reline pontic to form ovate pontic and cement
- After 10 week healing time restore...
Works beautifully... Also, if you have the 4 motor mill, use EF milling. Takes a long time, but the mills are phenomenal.
I just wanted to show a case that just got seated today. It was a bridge from 2=5. I would have preferred implants obviously, but the patient did not want to do the required grafting, etc... to do it. She was rather concerned about esthetics... so what do we do? I don't use e.max bridges in the posterior anymore and the high strength zirconia would have not looked good enough. I could have sent to the lab for a layered bridge... but I tried to use translucent zirconia instead. I have talked extensively about the short comings of this material. Even though the flexural strength of this material I used is 600mpa, there is no transfomational toughening present so it is much weaker than the zirconia that we all use same day. This is Copran Ultra Translucent zirconia from Empire Dental Solutions.
The result was excellent... will it work long term? We will see. The connectors were about 14mm2 on this and it was cemented. I fired it for 9 hours in the S1 furnace (cannot use Speedfire for this).
Just thought I would post as an option.
I saw a comment on the boards the other day that asked this question. It was funny because I am going through a case right now that I had some issues with this.
I don't exactly know how to answer the question to be honest. There are many different things i've heard.... things like the blanching goes away in 20 min or less,etc... The way that I have done it in the past was just by "feel". That is... I want to put pressure on the tissue and I can usually feel if it's too much by how it seats. If I have trouble, then I will adjust. It also will depend on anterior vs posterior and how much tissue I need to move.
Here is a case replacing 2 congenitally missing lateral incisors. He has been wearing a flipper for over 10 years and finally wanted some teeth. Here is the initial preop photo...
After doing the plan, we placed the implants guided in the site
I let heal about 3 months. Since he had a flipper, I just used healing caps that were flush with the tissue and adjusted his flipper for the provisional.
Here is how the tissue looked at full healing:
As you can see, I have a lot of tissue to move, especially on tooth #10. Now, here is the mistake that I made. I tried to move it too quickly. Meaning, I pushed on the tissue way way too hard. It was difficult and painful for the patient (I did not numb up). #7 was still painful, but not that bad because I didn't have to go as far...
Here are the initial provisionals:
How do I know I pushed too much too fast? Here is an iphone picture my assistant sent me two days later (it's her brother in law)
Yikes.... I had to have the patient in immediately, get the provisional out, recontour it quite a bit and put it back in. That with a chlorohexidine rinse healed the problem in about 4 days.... Here he is as of Monday:
So.. be careful. If you need to move the tissue a lot, do it in a couple stages and not all at once. You may get lucky and it will work... or you may end up having a significant issue like I did on this case.
I am pretty sure I have posted a lot of this before, but I wanted to post the entire case now that I am finished. Many of you in the courses have heard me tell of a good friend of mine that had a nasty trauma to his front teeth. It was a very difficult case to treat, but I think we got a reasonable final and he is very happy.
Here is how he showed up in my office the Monday after the accident. He took a blow to the face and vertically fractured both 8 and 9 all the way down.
I referred to my surgeon who was able to extract the teeth, place the implants, and do pretty extensive bone grafting. The one major compromise that we had was that the teeth were extremely difficult to remove. Because he had to incise the midline papilla with his flap design, I knew that we were going to lose the midline papilla on the final (I was right). I could have prevented this by placing custom healers right away (or immediate provisionals), but the surgeon did not feel comfortable with me doing this. I also could have been more patient with the treatment and let the ridge heal before implant placement or done more extensive soft tissue grafting. However, he was a good friend and I wanted to get him fixed up.... perhaps a regret that I would have not done with other people....
Because he had crowns on 7 and 10, I was able to remove the crowns and create/mill a 4 unit provisional for the healing phase. This really saved me because he would have had to wear a flipper or essix. With his job, that would have been a disaster for him. He is in front of people all day.
He wore the provisional for several months and here he was 4 months later. Notice the swelling above #8... we were freaked out thinking we were loosing the implant. Thankfully it turned out to be a loose healing abutment.
We then started the restorative process with Provisionals to attempt to form the tissue a little bit (although I knew the midline was not coming back at this point). I just sectioned the pontics out and left 7 and 10 provisionalized.
After another month and a half wearing these, we moved on to the final restorations (split technique with infiltrated zirconia abutments and e.max MT crowns on all 4 teeth)
While not a perfect result, I think it worked out pretty good for him. Sometimes, a long midline is required with implants on both of the central incisors. He was happy and he doesn't show everything when he smiles anyway!
I wanted to post a fairly difficult central incisor case that I just completed...
This patient came to me wanting to improve her smile. She had some chipping and wear on tooth #8 and an old PFM on tooth #9 that had a previous RCT.
The tissue was extremely inflammed on #9 and the margin was quite subgingival. I determined that she had a biologic width invasion here that was likely going to need osseous crown lengthening....
So first, I planned the case out using simple photoshop smile design...
Here is where she needed her gingival crest to be on 8 and 9:
Here is where I planned where her teeth needed to be to have correct proportions. Tooth #8 needed to be lengthened slightly and the incisal edge on #9 was correct based on her lip at rest photo:
Then I quickly morphed the teeth into the correct position using photoshop:
So... the plan was the following:
- Prep and provisionalize the teeth to the correct position using a diode laser to recontour the tissue based on the original plan
- Send her to the Periodontist to perform osseous crown lengthening (mostly on #9) to get the tissue to respond and eliminate the Biologic Width problem
- Allow the tissue to heal
- Fabricate the final restorations
After removing the crown on #9... I got another suprise... ouch:
I opaqued the tooth to try the best I could to block it out and finalized the preparations on both 8 and 9:
I made the provisionals on 8 and 9 and sent her to the periodontist:
Two months later after healing, we did the final restorations out of e.max MT shade M1:
There was still a little darkness coming from the root of #9, but overall I was very pleased (and the patient was thrilled). If you look at the smile picture, it doesn't show :)
This was a long and difficult case to do... but I feel because it was planned properly and the patient understood what was needed, it turned out pretty good!