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Last Thursday, as I was getting ready to close down my day and meet some friends for dinner, a new patient called up and said he broke his porcelain crown. So, we told him to head on over, assuming I would just patch him with composite or tell him to be careful over the weekend and that we would address it the next week. At first glance it looked like he just had a crack line on the facial of #9...the gingival inflammation could have been a clue that there was some movement of the restoration, as he reported that wasn't always there:
No big deal, right? Well, I touched it with an explorer and the entire crown crumbled off of the tooth...and now it is my problem. Sweet...so, looks like my Gibson's bone-in ribeye will have to wait(worth the trip if you come up to Chicago, FYI). How would we have handled this before CEREC? Try to free-hand a temporary, maybe slap a bunch of composite on there to get him through the weekend? Well, this new patient was thrilled when I told him that we could get his new crown completed right then if he was willing to stick around for a bit. So, cleaned up the preparation-the previous dentist did a nice job of keeping the lingual portion of the preparation above the cingulum, so there was still plenty of tooth structure.
The software spit out a nice proposal that only required a few minor modifications:
The lessons learned from this site and Level 4 in Scottsdale have really helped me when it comes to both composite bonding and my anterior CEREC restorations...just thinking about things differently has made a huge difference for me and my patients. I ended up restoring the case using e.max A-1 MT as he had already fractured one anterior crown and clearance was a little tight on the lingual. Added some texture and a little white to the line angles to give the restoration some added life, and then bonded in place using VarioLink Esthetic Warm:
I am looking forward to seeing how the gingiva responds when he comes in for hygiene, but it was certainly nice to be able to help him out...he was blown away by the technology and the fact that we were able to solve this big problem for him on the spot.
I know we all get frustrated and focus on what else we wish this technology could do for us, but this case really reminded me how fortunate we should be for the things we already can do. This would have taken a ton of work to get an even remotely acceptable result, but instead I was able to use CEREC to impress a new patient and get myself out of a jam. The steak was fantastic, by the way...medium rare, mushrooms on the side...just want to make sure I give all the information-sorry, forgot to take a picture of that!
.....to place an implant and graft simultaneously and achieve an acceptable outcome in this case?
Let me give you some background: the patient is a 74 yo male, medical history includes type 2 diabetes and hypertension, for which he takes meds and both conditions are controlled. He had #19 extracted at another office approximately 8 months prior to the CBCT images you see above. He has adequate thick attached tissue and restorative space. He has had a couple of other opinions provided already.
His ask is this: he wants an implant placed and any defects grafted in one procedure. He is aware that he will have to return at some point later on for the crown, he just does not want to have multiple surgeries if at all possible. He desires this because he's not getting any younger and doesn't want to spend any more time than he has to away from his job and his vacation house.
What do you think? Tell him he has no choice but to perform a ridge augmentation first? Go for it with the understanding that there may be complications that require more surgeries to correct?
As much as I like using my CEREC for implant restorations, the workflow for restoring a bridge is a little cumbersome. In order to restore a bridge from 19-21 using the chairside software, you need to scan the implants with Sirona scan posts, designate mutilayer single restorations for 19 and 21, split the restorations and mill just the abutment portion. You then need to either seat those abutments in the patient, pack cord, and scan them in as teeth in order to designate a traditional 3 unit bridge in the chairside software. The other option would be to take a physical impression on the implants, seat the abutments on that model and scan that back into the chairside software. If you have the premium software, you can designate a multilayer bridge and design it all together, but I've found those to be my hardest designs.
Now, I scan the implants with Sirona connect 4.5 using the Atlantis FLO scan bodies, that same day I approve the abutment design from Atlantis. By the next morning I have the core file of the abutments that I approved on a model that I can import into my chairside software and I design the traditional bridge. The next day, the abutments arrive from Atlantis. This saves me from either having to do a second scan appointment with the patient or from pulling out my old expired pvs material and doing a traditional impression.
These are a few photos of the process:
They also send an .STL file if you want to print the model with the abutments.
I normally request an insertion guide for bridges, so that I can go directly to the mouth with the correct orientation.
In my opinion, this is an easier workflow for sure. The abutments cost me $150 a piece (for titanium) and about $40 for the zirconia bridge block.
This isn't a novel post but for some of the new CEREC users, I thought I would share some bread and butter dentistry. I would rarely do crownlays during the BC (Before CEREC) days. As we all know the biggest challenge was provisionalization and you as the clinician had to be knowledgeable enough about materials to explain to the lab technician about material selection, color and translucency so you could get the results you desired.
Now with CEREC, there are a number of different materials at our disposal and no worries about provisionals. For this case, I had plenty of enamel to bond to and enough clearance so I could have used just about anything in this case. Typically my go-to for crownlays is IPS e.max HT (high translucency). I've used MT with success but I find blending the margins is a bit easier with HT.
Another thing I really try to focus on with these cases is smooth flowing margins. Unlike the days of gold inlays and onlays where sharp internal line angles and boxes were the norm, resistance and retention form are not my primary concern. With proper bonding, these do not come off.
For this case, I intentionally choose A2 HT because the cusp tips of the premolars where brighter. I selectively etched the enamel with 35% phosphoric acid, scrubbed the tooth with Adhese Universal for 20 seconds and bonded with Ivoclar Vivadent Variolink Esthetic Warm Plus.
Nothing earth shattering, but these are the types of cases where efficiency and predicatability are paramount for us each day.
Good afternoon everyone,
Recently we held a webinar to outline the process of sending a case to Atlantis for custom abutment fabrication. There are times when utilizing a laboratory would be more ideal than just using the Tibase.
Dentsply Sirona has set up a connectivity with the CEREC and Atlantis for those doctors that want to utilize this service. Please see the information from Dentsply Sirona on how this process works:
If you want to review videos on the process, please follow the following link where the entire process is outlined:
We are excited about the new connectivity between CEREC (provided by Dentsply Sirona CAD/CAM) and Atlantis (provided by Dentsply Sirona Implants). This comes as part of our ongoing commitment to serving the cerecdoctors.com community with great implant restorations that work with your digital workflow and to provide outstanding service to match. Take advantage of the special introductory pricing available for CEREC doctors only. If you’d like to get set up, follow these steps for an easy way to submit your implant cases:
We look forward to a great partnership. Please let us know if we can help you in any other way. Dentsply Sirona Implants
- Call our technical team at 800-531-3481 (option 6), to set up an Atlantis WebOrder account, link your Sirona connect account and set up your special pricing
- Order any IO FLOs needed for case scanning
Pre-op implant case plan in Galileos XG3D CBCT for Astra EV in the #31 position. THe tooth had exhibited typical endodontic failure with crack through furcation with 9 mm buccal pocket. Tooth was sectioned and extracted in multiple pieces preserving the site.
Post-op Informational CBCT was exposed for verification of exactness of guided placement.
Healing cap present. Boring.
Implant table visualized. CEREC scan was accomplished with scan post and scan body. File was sent via Sirona Connect to Atlantis.
Core file was returned and downloaded to CEREC but the abutment design required two iterations before the occlusal space management was acceptable. The Zirconia crown was milled and fired before the patient arrived and the case was delivered in less than ten minutes after removal of the healing cap with no adjustments.
Abutment torqued into position to 25 nt-cm as per Astra spec., plumbers tape placed into abutment and closed with Fermit.
Basic zirconia crown delivered with Fujicem RMGI. If you haven't watched Skramy's 7 videos for this worklow I would highly recommend that you take the time to view them. I made the mistake of checking them out AFTER (dope) beating through the case but it was still a good learning experience. The workflow is very doable given that we no EV parts and pieces yet.
Bitewing exposed to visualize the great fit of the abutment to implant table.
Crown cemented with superb marginal adaptation.
Nice Job JB
One of the things about having the in house ability is allowing you to rethink these cases. The provisionalization- not that is simpler, but it allows doing things you would probably not do if there was a lab involved from a cost or time standpoint
Hey any West coasters, late night people or early risers... I had meant to get this case posted earlier in the day or week, but hadn't. I'm presenting an onlay case to some other docs and wondered if anyone out there had thoughts on the prep, the design and pros/cons of the way I treated the tooth. Note - I am pretty much an A1 block guy, so don't harass me too much about the shade of the block! I have been doing these onlays since 2002 with very high success, but am training some other docs and want to see how many in the community would do an onlay type prep as I did here, or something LESS invasive, like a composite, or more of a full coverage crown.
Removed the Amalgam and recognized the mesial crack was extending onto the pulpal floor:
After shaping around the mesial fracture, noted the pulpal fracture on the DB cusp, but since the crack was on the floor only, decided not to hood the entire molar:
THoughts on this? Better to hood the entire buccal?
After shaping down, preparing with very slow speeds and finishing the margin, didn't like the 2nd dentin and the high MB pulp horn:
So placed some CaOH:
And after cementing and comparing the final occlusion, thought we looked pretty good on this restoration:
I have a tendancy on molars that have had heavy occlusion with large amalgams to reduce the overall bite so from the initial biocopy, you can see the reduction of the heavy bite and I'm wondering how others would have managed this case. Original biocopy: Adjusted occlusion:
Thanks for any thoughts! Curious how many would have just done a composite here... how many like the onlay.... and how many think this should have been full coverage- or MORE coverage than what I did here. Appreciate the feedback!
Access fill, whether screw or endo, always seems to be a topic of restorative discussion. What can we do to prevent the dark shadowing or grey appearance? We spend all of that time on the crown or implant solution then compromise the final esthetics with a poorly masking access fill. This case shows a screw retained implant crown. Teflon tape is first packed into access opening directly over the abutment screw(about 1/4 to 1/2 inch long). Unlike a cotton pellet, teflon tape can be well packed into the access opening to prevent the screw from backing out. Tetric EvoFlow Bulk Fill Shade A (Ivoclar Vivadent) is layered directly over the teflon tape, followed by Tetric EvoCeram (A2). The block is an emax MT (A2).
Dan Butterman did a great job this week presenting a webinar on restoring implants with the Atlantis system. I've done several cases to date working with DSG Clearwater Dental Lab. These cases can also be done with Atlantis directly now that Connect 4.5 has been released.
The workflow is very simple. Remove the healing cap and insert the Atlantis IOS scan body. These are implant system specific like our Sirona scan posts. Take the scan in Connect and digitally ship the file to DSG in this case or Atlantis directly through their portal. Now we just lt the lab do all the work. A very CEREC friendly abutment with excellent emergence is milled after verifying the design the lab sends for review. I've been using titanium exclusively, but there are gold coated and zirconia abutments available. The fit of the crowns to the abutment is outstanding. When the patient returns the abutment is simply torqued in and seating is verified by radiograph. The crown is cemented via traditional methods.
For the past many years I have been stubbornly fabricating all of my own abutments as I just refused to work with a lab. With the ease of this this workflow I am happy to have another option. The price point is going to be in around $300-$350 for abutment and crown. Another option is to have the lab mill your abutment and then email the Core File of the abutment design. The Core File is uploaded into the chairside software and we are able to design and mill our own crowns before the abutment even arrives in the office. The abutment alone is going to be in the $150-$200 range. This is slightly more expensive than using a tibase system, but for the many users not taking advantage of this feature, the scan and send may be appealing.