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There are very few procedures that are more profitable and efficient than restoring implants.  Typically, by the time the implant is ready to restore, the patient is committed to treatment and ready to get their tooth.  This usually reduces the number of financial issues and limits no-shows and cancellations.  The icing on the cake is if you are restoring with CEREC, you can count on the cost of restoration (whether custom abutment and crown or screw retained restoration) to be considerably less than it ever has been.

But, we all know that ideal world doesn't happen every case.  Most of the "complications" I have experienced are due to  poor coordination of care with the surgeon, or improperly setting expectations from the patient.  I've see where the patient agrees to surgery at a specialty office but forgets about their financial responsibility for the restoration.  I've experiences the surgeon including an abutment in the cost of surgery, which means the restorative specialist now is stuck with a stock abutment that the patient has paid for, when in reality we would prefer to use a custom abutment or screw retained restoration.

Even worse than any of these financial barriers that can be raised is when the surgical outcome deviates from ideal, which creates a fundamental dilemma in how to restore the implant.  We've all see cases where we have to go through all kinds gymnastics simply to restore the implants.

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Wouldn't it be nice to have something predictable and straightforward to design instead?

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To predictably set yourself up for this type of straightforward, no-nonsense restoration, properly planning the surgical case from the beginning is an absolute must.  The general dentist acts as the quarterback for our patients.  We create the plan and then either hand off to another person on our team or throw the touchdown ourselves.  Something I see too often in dentistry is the "hands-off referral" where we send the patient on their way with a referral slip and don't even hear anything about the patient until a progress note from the specialist.  This is not a good approach in general, but especially when it comes to implant dentistry.   Whether we provide the surgical services ourselves, or send the patient to a specialist, we can make our restorative lives better and ensure our patients have a better outcome by planning the case properly before we begin.

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In this case, I planned out the surgical aspect by merging Galileos and CEREC data.  The way I plan this out is with the restorative outcome in mind from the beginning.  I can account for proper angulation to allow for a screw retained restoration in both the #5 and #12 positions.  I also ensure proper depth of placement to allow for the ideal emergence profile.  Finally, I made absolutely certain to avoid an anatomic concerns, like the sinus cavity, adjacent teeth and implants, and the thin buccal plate.  I then fabricated a surgical guide based on this plan that would allow me to execute exactly as I planned out.

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The beauty of all this hard work and planning is when the implants were ready to restore, I knew I would have no trouble at all obtaining great results with proper angulation and depth to allow for ideal screw retained restorations. The restorations were imaged, designed, and fabricated with the CEREC tibase workflow using e.max LT as the final material.  Custom shading created the final lifelike touch to the restorations

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Sometimes there are cases that need attention from a specialist colleague.  Using this workflow and this way of planning out the case allows us to still get to this point from a restorative aspect.  And if we plan the case out properly from the beginning, and follow proper guided surgery protocol, we all can see this type of result from all of our implant cases

27 Feb 2018

Posted by Jason Retter on February 27th, 2018 at 02:48 pm
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He broke the distal half of his central off into the attachment, crestal area. None of these teeth respond to cold, including the broken tooth. No teeth are tender to percussion. 

He wants a simple solution and I'd like to provide him with one. I can do a composite restoration and hope for the best. I'm concerned though that I'm gonna cause gingival inflammation by violating the biologic width and/or a periapical abcess. What do you think is the right call here? I think I need to address the other central as well before the same thing happens.

 

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22 Feb 2018

A child that I diagnosed with Hypodontia 12 years ago and referred to a pedodontist returned last week. 

He is a senior in high school now, and would like to be able to smile confidently. 

Aside from being too young for implants, the lack of permanent teeth never allowed the ridge to widen so extensive grafting would be necessary for any implants to be placed. 

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I am thinking of opening his bite with some overlays on the primary molars.  Then single wing MD bridges on 8 and 9 to replace 7 and 10. I don't want to do anything irreversible to the incisors until implants are an option.  On the Mandibular incisors, I was thinking of trying some Veneer / crowns . The just some composite bonding to correct some of the other areas.

 

Any thoughts are appreciated

Thanks

19 Feb 2018

Posted by Bob Dawe on February 19th, 2018 at 08:52 pm
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There is a use for all of the tools in the mill (or manufacture) phase of the software.

Of course we all use the sprue tool to get the sprue placement away from the perfect proximal contact we just created. 

Then there is the move tool which we can use with the multilayer blocks to alter where the dentin and translucent areas of the crown will be.

And both tools can be combined to effect a more gradual transition of shades on these blocks.

But both tools and both aspects of the move tool can be used to make an exceptionally large crown fit into a block that at first proposal would appear to be impossible.

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13 Feb 2018

Posted by Daniel Butterman on February 13th, 2018 at 06:48 pm
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With more people expanding into Atlantis for some CEREC implant restorations, I thought I would post about the ability to print the core files.  Keep in mind that this is an option that you will soon be able to order through Atlantis, but it's nice to be able to do it own your own if you have a 3D printer.  I use it for my larger cases and I also do it for cases that I send to the lab, since labs have a very difficult time printing Atlantis core files for stacking porcelain.  The .STL file can be found in the .ZIP file that Atlantis sends to you after you approve the abutment design.

In order to print the model, a base needs to be added and then a second model needs to be made with all of the gingiva removed to have a clear view of the sub gingival margins.

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In order to remove the tissue, you just select the abutments and delete everything else.

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You then add a cylinder and combine it with the abutments to hold them in the proper orientation.

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Both models are printed and the restoration can be tried on and finalized.

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09 Feb 2018

Posted by Liz Manji on February 9th, 2018 at 10:40 am
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VITA INTRODUCES “SMART” FIRING UNIT

FOR CHAIRSIDE RESTORATIONS

                                  New VITA SMART.FIRE® boasts easy-to-use interface with one-step

material selection and program start

YORBA LINDA, Calif. (Feb. 7, 2018) — To meet the special needs of chairside milling dentists, VITA has introduced the VITA SMART.FIRE, a fast, efficient and compact firing unit for chairside restorations, including the crystallization, glaze, stain and corrective firing of all common chairside materials.

Featuring an intuitive user interface, materials may be selected in one simple step. In addition, customizable material-specific programs are already pre-installed for simple firing. The VITA SMART.FIRE system includes a durable firing unit for robust firing technology and reliable function, an intuitive touch control unit with a high resolution, 10-inch display and an integrated service drawer for easy access to important accessories, such as firing trays and platinum pins. The fully automatic temperature calibration produces reliable results, and a software-based assistance function is also available for supported, step-by-step firing.

With the VITA SMART.FIRE, CAD/CAM restorations can be completed chairside, even for monolithic, ceramic restorations. The convenient, compact size means VITA SMART.FIRE can also be set up quickly and simply, and is mobile for use in any treatment room.

VITA is a leading provider of innovative dental products. From premium denture teeth and veneering materials, to digital shade measurement, furnaces and CAD/CAM restorations, VITA helps laboratory technicians and clinicians deliver high quality and esthetic results to patients quickly and efficiently.

For more information on VITA SMART.FIRE, visit www.vitanorthamerica.com or call 800-828-3839.

 

 

08 Feb 2018

Posted by Daniel Butterman on February 8th, 2018 at 06:05 am
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Doing veneers in a single visit with CEREC still blows me away.  These are e.max MT, with the case completed in 2.5 hours (with 2 mills).

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07 Feb 2018

Posted by Ross Enfinger on February 7th, 2018 at 10:15 am
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The following case was a rewarding smile makeover for a young patient who had always hated her smile. Of course, we always start our evaluation with the FGTP template, which shows us that this was both a tooth size and gingival asymmetry issue. I did the wax-up, transferred the wax-up to the mouth, and completed the interim gingivectomy and provisionals, after which the periodontist did the definitive crown lengthening. After a few months of healing, it was a rather predictable and efficient transition from the approved provisionals to the final Cerec restorations using segmental Biocopy. There's nothing in dentistry more fun than this!

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06 Feb 2018

This case represents how vital an efficient workflow can be when managing our patients. The patient presented initially with diffuse symptoms in the upper left quadrant. She reports a history of fibromyalgia and Ehlers Danlos syndrome. She has an extensive dental history, many times with significant post-operative discomfort following treatment. The patient reported sporadic pain that would vary in intensity, sometimes with no stimulation. CBCT showed no signs of periapical or radicular disease and the diagnostic testing was inconclusive. Due to the subjective and objective data giving no clear reason for her pain, I referred the patient was referred to an endodontic colleague for evaluation.

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After consultation, root canal therapy was completed on both #12 and #13 and the patient was returned to my care. Because of the patient’s history with difficulty following dental treatment, I requested the endodontist fill the access openings with core build up material which reduced the number of visits and limited the patient management complications following her first stage in treatment. I also waited 8 weeks prior to initiating full coverage crowns as final restorations.  The following outlines my workflow meant to maximize efficiency and speed without sacrificing quality.

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Anesthesia was delivered and while it took place, I completed my pre-operative imaging. 5 minutes later, the Isolite was in place and I began prepping.   Prep design was fairly straightforward, with a full coverage traditional style preparation to ensure adequate strength to the endodontically treated teeth. Retraction cord was packed around the preparations to displace the tissue and I started imaging 30 minutes into our appointment.

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Since these teeth had only occlusal access resins, I was able to be very conservative with the preparations circumferentially. Yet, because irritation to the pulpal tissue was not a concern, I was able to reduce enough occlusally to obtain adequate thickness. Utilizing a material that does not require firing is a great way to keep the appointment moving along in an efficient way. As the models finished processing, I was deciding which material I wanted to use.

To me, this is the ideal case to use Celtra Duo polished only and bonded without a firing step. I obtained > 1.5mm of ceramic thickness which will provide more than adequate strength to the restoration. I prepared very thin margins along the facial aspect of the preparations, which typically requires bulking out the ceramic with many materials to avoid chipping. However, due to Celtra’s milling characteristics, I felt comfortable with ceramic thickness of 0.6mm and experienced no chipping whatsoever. At this point my design is done and sent to the milling chambers and we are 40 minutes into the appointment.

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The manufacturing process took less than 9 minutes total and I got to listen to the sweet stereo sound of dueling MCXL milling chambers fabricating the crowns. Polishing the restorations to a high shine, which gives Celtra fantastic strength in addition to its wonderful appearance, took another 5 minutes. Try in and preparation of the ceramic was another 5 minutes and we were ready to bond in place. The internal surfaces of the crowns were prepared with HF etch and silanated. The crowns were then bonded using Dentsply Prime and Bond Elect with Calibra Ceram. The excess was cleaned away, occlusion verified, and a bitewing taken to verify no remaining cement, and the patient was dismissed 1 hour 15 minutes after starting anesthesia.

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In this case, time was of the essence. Our patient had experienced clinical open lock, TMD symptoms, and overall pain after some of her previous dental visits. Having the ability to finish two full coverage crowns in this amount of time was huge benefit to the patient, a good use of my chair time, and a profitable procedure for the practice. When I have these types of cases, I will be sure not to double book myself in another chair at the same time. I want to devote the time needed to ensure the visit happens in an efficient manner.

24 Jan 2018

Posted by Mike Skramstad on January 24th, 2018 at 12:57 pm
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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.

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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

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After rough prepping the teeth, we transferred the waxup to the mouth and then did final depth reduction

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Here are the final preparations:

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And here is the final result.  Vita Mk II 1M1

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