Blog Author: Mike Skramstad
I am posting this for a couple reasons:
1. This is the first full mouth reconstruction I have done with Primescan. It was amazing and yes MUCH easier than with Omnicam for comprehensive treatment
2. We have has many questions as to what we are doing in our 4B course we have now available. THIS IS ESSENTIALLY IT! How do you execute larger more comprehensive cases with a digital workflow. If you are interested in this, I encourage you to attend. I will be answering any questions you may have on this thread... but nothing replaces a workshop on advanced topics like this.
So some brief background. This patient had two rounds of ortho and orthagnathic surgery. She had previous veneers that were destroyed over the years and with ortho (removing brackets, etc...) and she wanted a new, yes BRIGHT smile, and needed her occlusion restored.
I executed this in two visits....yesterday and today. Exhausting days for sure, but was able to complete it because of proper planning and knowing how to execute it. I just completed it, so the pictures are immediate post op.
I will post the pictures below and we can discuss it however much you all would like:
This case was pretty fun that I just finished today:
Patient wanted midline diastema and rotation fixed and also stated that she really did not like the translucency of her edges:
I scanned her at the hygiene appointment, designed two NO PREP Tetric CAD veneers over 8 and 9, and 3D printed a model to fit them on:
We bonded them in today with Variolink Esthetic light and did some minor bondings on 7 and 10
I suppose I could have done with ceramics and the esthetics would have been a touch better, but no way could I have milled them this thin. I'm liking the idea of Tetric CAD MT as a no prep veneer material
Here is a technique that will save you time when provisionalizing implants.
Patient needs tooth #10 extracted and grafted. At the consult appt, I took a scan of just his upper teeth (has an anterior open bite)
I exported the .stl file and put a base/hollowed out with inLab 18 and 3D printed the model
Next, I went to the Omnicam and selected Bridge Mode (veneer #9 Biogeneric and pontic #10 Biocopy) and scanned the 3D printed model in as the Biocopy. Next, using a carbide bur, I went ahead and cut out tooth #10
We then fabricated a maryland bridge out of GC Cerasmart...
All ready for surgery next week!
This is a case that I've literally been working on for 10 years... interesting to see patients this long and treat the case.
In 2008, this 12 year old came into my office with a fractured #8 from a trauma. The tooth was fractured pretty good and needed endo. After endo was done, we bonded in his old fractured piece of tooth and added to it with composite and prepped a minimal thickness veneer.... and restored it with Vita MK II
I knew that eventually this would have to be redone because he was not done growing and eruption would change his situation quite extensively over the years. He kind of disappeared from my office for awhile and came in again last year. Just like we thought, the tooth had erupted and changed over the years and needed a new full coverage restoration.
And here is his final restoration (Vita Trilux) completed this year
What a fun case to complete after all these years!
I know others have posted different techniques using other softwares to execute Essix retainers. I don't think anyone has done it the way that I have though, so I thought I would share...
If you have heard me speak about my feelings on 3D printing, I love it.... BUT, I will not completely love it until I can be 100% digital for all procedures. Now theoretically you can do that now, but I want it to be efficient. That is, I currently mostly print models and guides for esthetics and implants. What I want is to be able to handle everything from bleach trays to essix retainers, etc... I basically want to eliminate all impression materials completely from my office. For this, 3D printing needs to be fast and also a bit more automated I believe. Once that is the case, I would certainly be willing to pay more for a 3D printer if it had more applications like this.
So.. here is a case I did with the inLab software. I know that most of you do not have the inlab software (in US), but it gives you an idea of the possibilities that hopefully we will see at some point.
Patient missing tooth #26. Has been wearing an essix retainer long term that he broke.
Scanned with the Omnicam:
Exported .stl high resolution and loaded into inLab 18. From there, designed a crown in the space:
After design, virtually seated and added a base to it:
3D printed it in grey resin (100 microns Z)
Block out undercuts and used Ministar and 1mm Clear Splint Biocryl :
Now, the best part... go into inlab 18 software, reverse the virtual seat and choose the original layer, export the .dxd file, import into CEREC and then mill the tooth (composite block). Then insert it into the Essix...done.
There may be cheaper ways to do this, but this was super easy and my guess is that it will be very predictable. That is what is important to me.
I have had mixed feelings about the Katana (especially vs e.max cad) since using it. On one hand, the Katana STML looks and fits fantastic. On the other hand, you can expect it to take a good 20-25 min longer than a typical e.max (if glazed) and a little less if polished. I have gone back and forth if the time is worth it. After using it for awhile, I found myself starting to go back to e.max CAD due to the time. After a little more thought and clinical results, I have decided that in a lot of cases, it's worth the extra time. The stuff just looks and fits fantastic...AND there is better detail.
That being said, the other question is should you glaze or polish. I have done both and they both work out nicely, but I have realized that you have to be a bit careful about shade when deciding how you want to finish it.
As a general rule of thumb... polishing zirconia tends to produce a pearl effect, but it ALSO will lower the value. For that reason, I would tend to choose a shade that matches the shade you are trying to achieve (when polishing). As you can see in the slide below, the company recommends one shade brighter when polishing due to the decrease in value... but that might be overkill.
If you are glazing, It will increase the value and make it brighter. In that case, I would choose a shade one to maybe even two shades darker than your target shade.
Here is a case that illlustrates that. Both were done in A3 Katana STML. Tooth #13 was polished and tooth #14 was glazed. Both were clinically great... but notice the lower value of tooth #13 that was polished.
I hope this helps
I haven't posted a case in awhile... thought I would post one that I just finished...
Preop situation: Patient had very old veneers on front 6 teeth. He wanted to change them out with a "whiter" solution and also wanted a fuller smile.
We decided to do the front 8 teeth to take care of his buccal corridor issue. We imaged with Ortho software and sent to lab to have a digital waxup done
After rough prepping the teeth, we transferred the waxup to the mouth and then did final depth reduction
Here are the final preparations:
And here is the final result. Vita Mk II 1M1
I thought it would be a good exercise to go through an entire implant process documenting a failure of a healthy bicuspid. I also will include a couple tricks at the end on how I dealt with a small issue.
Healthy tooth #4 as taking on standard intraoral photographs and radiograph on routine cleaning appointment
One year later, she came in with significant symptoms on the tooth and it was very evident what had occurred:
We treatment planned an extraction and site preservation graft and allowed it to heal for 5 months time. After healing the site was ready for implant planning and placement:
After 3 months of integration we started the restorative process. We scanned with a tibase instead of a scanpost in this particular case and took an xray to verify the seating:
We made a decision to use a multilayer technique on this case instead of screw retained (which would have been possible) because I prefer the ease of delivery of cement retained implant restorations, but I also like having more material options. In this case once we split the restoration and had proper thickness of the veneering structure... there was a problem of the tibase sticking through the abutment.
I left the design as is and milled the abutment out of zirconia and the crown out of e.max HT using EF milling on the 4 motor milling unit:
Once the zirconia abutment was seated, you can see that the parts fit together perfectly
However, when bonding the tibase to the zirconia abutment... the tibase was infact poking through the zirconia abutment just like the design showed and this obviously prevented the parts from seating properly
To correct the issue, you can simply use the abutment as a reduction coping and "flush" the tibase that is sticking through to the zirconia abutment. This should not affect the final restoration if it's just a little bit like in this clinical case
Once complete, everything was delivered in the mouth. Besides the shade being a bit light, the overall process was a success.
I hope this process helps some of you in the tighter interocclusal spaces where you would like to use the multilayer design mode.
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.