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Here is a case that I just cemented this morning. I couldn't have imagined this workflow until taking Level 3. Thanks Sam, Mike and Mark!
Visit 1: Extraction, immediate implant placement with surgeon. Custom healer, maryland bridge with myself. Both of us were finished in just under 2 hours.
Visit 2 (today, 4 months after visit 1): Custom abutment and final crown delivery.
There was one 2 minute appointment two weeks ago to check the final shade since the patient was bleaching.
The patient initially reported with #8-crown, post and some tooth in hand. At the initial visit, I took two preop scans. One for the biocopy with the tooth back in place and another with the crown back out to fabricate the Maryland bridge.
The extraction was completed and an immediate implant was placed. I personally like to fabricate the entire crown out of enamic when making making a custom healer, so I can get an idea if my design is on the right track. I then mark the crown where I want the custom healer to be and cut it down extraorally. I then cemented the already made maryland bridge in place.
Since I liked the look of the temp/custom healer, I split the design and finalized the custom abutment and crown. Staining and finishing is truly an art that I'm constantly trying to get better at. I know some of you are truly artists on here. The patient was ecstatic, so I was too. I am fairly confident the papilla will move down over the next few weeks.
I know this was technically 4 visits, but the main procedures were done in two with some planning.
Visit 1: Emergency recement with a couple quick scans (15 minutes)
Visit 2: ext, implant, custom healer, maryland bridge (2 hours)
Visit 3: Shade check (30 seconds)
Visit 4: torque custom abutment and cement crown (3o minutes)
I can't imagine going back to the "traditional" implant workflow!
So had my last work day of the year lined up, light work load Friday, today, and then your friends wife comes in. Her chief complaint was the aesthetics of her front teeth and wanting to get a new smile for the new year.
With everything going on, I was pretty hesitant to take it on and to do it in one visit. The bite, the diastema, and the gingival zenith really concerned me. But we did have the bridges and the starting point of the teeth going for us. After going over all my concerns with her, we decided to proceed with the case, something I definitely wouldn't have done without having a Cerec and the crutch of 4.5.2s amazing initial proposals. Being super motivated to get a new smile for the new year, she was okay with, at worst, using the crowns as temporaries. Luckily, although I wasn't the biggest fan, she absolutely loved the end result, hug/teary eyes and all. Just shows that sometimes we really are our own hardest critics. Now onto the new year!!!
I was Mentoring Level 6 this past weekend, and Farhad usually shows a Sonic Weld case.
I have been using Sonic Weld for a couple of years now, and I have found it to be very predictable with very few complications.
I have had variable results with cortical bone grafting (resorption), and membrane exposure and soft tissue retraction issues with titanium mesh, so I really wanted something more predictable and easy.
This is a case I did yesterday. This is a typical thin ridge free end distal extension edentulous area in the mandible. She wants at least 2 implants in the #19 and 21 areas.
The sequence is as follows:
1. Full thickness flap, multiple small perforations in the cortical bone.
2. Drill the holes for the pins and Sonic Weld them into place.
3. I usually weld the membrane onto the inferior pins first, pack the space with allograft/PRF, then bring the membrane over and weld to the superior pins.
4. PRF cover over the Sonic Weld membrane, loosen up the flap so it can cover, then Vicryl sutures for closure.
Here are some pictures:
This was a case I did this week just before hopping on a plane to travel to Scottsdale. The patient called and reported he had "chipped his tooth". No big deal let's give him a 30 minute emergency time slot. Upon exam he actually fractured the facing on #6. Game on! The original prosthesis is a 12 year old 3 unit PFZ bridge. Now he needs a new bridge. Before CEREC this was a challenge on a few levels at this time of year. In an insurance based practice like mine. there is no way to get this project done before year end. This means all of the insurance benefits this patient has for 2017 would go unused. The other hassle is that with 2 major holidays coming this month, we wouldn't get the case back from our lab until early January. Nothing better than wearing a temporary bridge for 4 weeks during the holidays. I guarantee you I would get a phone call from this guy at the worst possible time during the holidays.
The way we handled this case was to take care of him that very same day. A same day 3 unit bridge for us is a 2.5 hour visit whether we use zirconia or emax. If you have multiple operatories this is a really simple work flow. Remove the bridge, refine the preps, image and design. This will take the average dentist 30-60 minutes. Even if it takes 90 minutes, that is all the doctor time needed as the rest of the time is simply milling and crystallizing. After the bridge is processed the cementation is another 15 minutes. At most this procedure will require 1.5-2 hours of doctor time. This is a $3600 procedure with a lab bill of $105 (block), which is great hourly production. When you consider you are likely doing additional procedures on another patient or 2 during the processing this is a great day. Don't worry about the patient sitting around for 2-3 hours. These folks are thrilled to get their bridges same day!
I think we sometimes forget all of the great materials available to us to solve our patients clinical needs. The single unit anterior restoration is the most challenging esthetic procedure we face. Anterior esthetics require the consideration of not only the base shade, but also characterization needs, shape, texture, and light reflection. And just when we get ALL of that correct, our adhesive bonding choice could compromise the final outcome.
This patient presented to the office with a fractured #7 veneer. She had considered replacing it in the past but the repairs had held up and were fairly esthetic until recently. I chose Empress Cad (Leucite Porcelain) for its translucency and its ability to let light (even with the LT) to pass through it and allow the color of the tooth to increase the natural look of the final restoration. It can be easily textured in the software and polished to the desired effect. Variolink Esthetic Cement was chosen for its long term shade stability (100% Amine Free), multiple shade options, and easy clean up. We used neutral shade for this case but it also comes in light and warm shades.
Currently, my preferred way to use an Atlantis abutment is with a cement retained crown because the workflow is so slick and seamless, but going screw retained just takes a bit more work. This is a test case on a model that I did to look at the steps for a screw retained crown. When choosing the abutment type, you select a screw retained custom base. The core file that is sent back to you will contain the screw access position and orientation in the gingival mask folder (took me a minute to find it). You just need to use form minus or circular shape tools to reduce the porcelain in the area of the screw so that when it mills you'll see the dimple of where to cut through.
This patient presented from another dental office in town needing 2 crowns. He was in attendance at a CEREC technology presentation I gave several years ago to our local Kiwanis Club and he decided that he wanted his crowns done in a single visit the CEREC way. I can post photographs later after the gingiva heals. It is obvious why I wouldn't consider allowing this dentist to provide any dental services for me. He was obviously absent for the lecture in dental school in which were presented the techniques for burnishing matrix bands to produce a proper convex inter-proximal contour for complex amalgam restorations. Or, he just doesn't give a damn, or it's the best he can do. That flat inter-proximal contour and marginal ridge only contact would have landed this guy on the bolo squad when I was in school at the University of Illinois. But he is an Iowa grad. At least he didn't leave a huge gross overhang. #19 had a fractured DL cusp and he was packing food, so that was his chief complaint. I insisted on replacing the poorly contoured MO amalgam on 18 because recontouring that restoration would have resulted in an over contoured distal on the crown and leaving it would not have totaly solved the food packing issue.
Post op bitewing, shows a little bonding resin on some soft tissue tags left over from the laser troughing. I removed most of them with a Soft-pick and the rest of them will slough. This bitewing also shows the next project, removing and replacing the PFM on #14--hopefully that decay hasn't progressed to the point where the tooth structure under the crown is totally mush. What is also obvious from the post op bitewing is that, super-tech that this other dentist is, he butchered the distal of the PFM on #14. Therefore, the mesial proximal of that amalgam is over-contoured and can be satisfactorily reshaped to provide a nice contact and eliminate the food packing in that area. Unfortunately, this patient has some pretty average, for my area, dental work. The dentist who produced this dental work needs to care less about his bottom line, and care more about the quality of the services he provides.
Just thought I would present a case where I had screwed up(I have plenty) earlier on in my CEREC career and I finally had a chance to make it right. Ironically, I am speaking to our dental students next month on Iatrogenic dentistry, so I have been putting the presentation together, and this case will be in it. This patient presented in early 2013 for a crown on #8 due to a "dark tooth" after some trauma he had several years earlier. He also had some old bonding on 9 but he wanted that left alone as he had it replaced multiple times before and it was now stable. I was just starting to play around with anteriors with CEREC, and obviously I had a lot to learn. I took a quick shade, decided A-2 seemed to match, and we went forward with an Empress Multi block in A-2. I still love Empress Multi for anteriors, but when I first started using it I was almost trying to force fit it into situations where maybe it wasn't appropriate. At the time, the patient was very happy as his tooth had been pretty dark and so he was happy just to have a significant change. Once I heard he was happy, I couldn't bond it in fast enough! When I saw him for a follow-up, he was still happy, but I could tell that I clearly had missed...I discussed with him trying to replace it but he didn't feel there was any reason to.
Fast forward to this week, and he is unfortunately getting divorced, which is causing him to re-assess everything. He mentioned that in pictures he noticed his tooth looked dark, and he was wondering if I would still be willing and able to replace the crown. Of course, considering I always hated his crown more than he did, I was happy to oblige...these patients are our advertisements to the world, so I would much rather have him looking as good as possible. The lessons learned here and in Scottsdale gave me a totally different way to assess the case and think about the final restoration, especially with regards to material choice and focusing on the value, texture, etc. So, we removed his existing crown, refined the preparation, and fabricated a new crown in e.max A-1 MT and bonded it in place using VarioLink Esthetic Light:
While it isn't perfect, and looking at the pictures I may need to adjust the length slightly when he comes in for a follow-up, this is obviously a much more acceptable result...hopefully this helps his confidence as he moves into the next phase of his life. I was only out a little time and the cost of materials, which is a small price to pay to be able to sleep at night knowing that I have done right by my patient. Now if I could get him to let me replace that bonding...
The real takeaway is to focus on value and texture, especially when it comes to anteriors...if you haven't taken Level 4, it is an amazing course that can really help out with these aspects. And if something isn't up to your standards, don't be afraid to make it right. We have such an advantage in being able to control the cost and the outcomes we obtain, so take advantage of it! Your patients will appreciate it, your team will have more respect for you, and you will feel better about your practice as well.
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.
My parents were heading out on the town with their best friends when they got a phone call canceling because his friend had broke his tooth. My dad had such a simple solution. "Go see my daughter! She can fix it in a day!!!"
This can be a tricky situation. He has a dentist who did a full mouth rehab. It's amazing how much I have learned being a CEREC doctor and being involved in study clubs like Spear and Seattle Study Clubs. One thing that he causally mentioned was that his lower teeth kept breaking... Obviously this is not an ideal bite.
So here is a plug for the virtual articulator. His previous crown broke exactly where it said it was going to. Such a smart computer we have!
I have no idea what material was used with his previous work, but I used e.max B1 LT for #23. I was excited about the match. I didn't adjust his other crowns at this point. Maybe someday. Today my job was to fix the broken tooth to get them out on their date night. This was single tooth dentistry, no staining or magic other than it was fixed in a few hours and I am confident that this one wont' break ;)