Blog Recent Articles
I had the incredible opportunity to speak at DS World this year and was asked to post the cases I presented. All three of the cases I will post were done on a random day in my office. The same random day. It was a day that didn't go nearly as planned but at the end of the day my patients were happy and my team was profitable. It was a win-win. Here are some tips and tricks I've learned over the years from others willing to share their cases before me...
What's the first thing I think when I see a case like this? This patient needs comprehensive care. He needs ortho in an ideal world but declines the option. The dark tooth on #9 had never bothered him until now due to a wedding in the near future. Tooth #9 has had previous endo. When I see a bite like this my first instinct is to use BioCopy because I don't want to mess with nature. I also lean towards e.max. It is strong and forgiving and easy to stain and glaze.
The burs I actually use isn't really that important but here are a few tips on preps. For efficiency sake, use a pattern and stick to it. The best advice I got was doing axial walls first, then reduction, and then smoothing off any sharp corners. I try to use no more than three or four burs and always in a specific order. I see so many doctors get caught up in the small details and determined to use as many burs as possible going back and forth between them. This is not efficient. Have a system. Don't bounce around.
I also use a lot of opaquers when I work on anteriors. This allows me to use more translucent blocks by blocking out the color underneath. My personal choice is Cosmedent's opaquers. In this case I chose A2 so that the substructure would match that of #8. These opaquers have a consistency like flowable composite and that is how to treat it. Etch, bond, add the opaquer and then image.
This is a perfect case for the articulator function. I will be honest, I wasn't using this much in the past until I went down to Scottsdale to mentor and I think Sam was telling me how much it has improved and can really help out with post op sensitivity. I decided to see if this was true so we started tracking it in my office. We decreased our post op visits by 43%. Crazy! Of course there could be other factors but we don't believe we changed anything else other than starting to use the articulator function to remove interferences.
It's pretty obvious that #9 would cause an interference. It's longer than #8 after all... but this was my first mistake in this case. I assumed that of course he would want his teeth even! You know what they say about assuming...
My other quick design tip is to close the gingival diastema (or the dreaded black triangle that looks like pepper) from the lingual using the Shape > 2D Circular tool.
Here is the immediate seat. It looks a little low in value which is normal when the tissue hasn't healed all the way. My assistant did a great job staining the tooth trying to mimic the coloring on his other teeth. He was happy and left the practice only to come back about an hour later. The problem wasn't that he didn't like the shade, it was that he couldn't "bite the skin of his lips". He was pretty distraught about this. I gave every explanation of why his teeth should be even and that he would get used to this, but to no avail. He wasn't leaving until this was fixed. Out came the consent form because I wanted to be clear...
So I cut off the freshly bonded crown and remade it. My assistant was helping out with another patient so I got to play with the staining on this one... I also was able to use the same block to mill out the second crown so that was a bonus.
I really love using white as a distraction. Matter of fact in James Klim's lecture he calls this the "Art of Distraction." It just means that you get to be a little creative in your staining. Don't use super straight lines with your stain. That is what makes it look fake. Have fun with it. Light touch, feather like in design. I used e.max stains for this e.max A2 MT crown. More tips on staining and glazing in following cases... Stay tuned!
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:
IMPLANTS TOO CLOSE TOGETHER
Restoring implants with CEREC technology is now quite common and just about everyone in the cerecdoctors.com community is quite adept at handling the parameters. I've been placing implants for 5 years and restoring them for much longer. Other than the occasional odd case with aesthetic difficulties, I've never been stumped with anything bizarre--until recently.
I recently placed two implants on my assistant, Nadine, for sites #2 and #31 (see pictures #1 and #2). The upper was placed first, while the lower site was healing after I asked my oral surgeon to build up the ridge. I then placed the lower implant just like the upper, scanning first in CEREC, designing a final crown into proper alignment and occlusion, integrating into the SIDEXIS 4 software, and making CEREC Guides 2's. The implants were placed with ease.
Pictures #1 & 2
After appropriate healing, I placed scan posts/scan bodies on both implants to restore them. I designed the respective crowns and got bizarre proposals, because the implants were too close together in centric occlusion. Just to verify, I placed tibases on each implant, and sure enough my patient was unable to close her mouth all the way. Realizing that I needed to study this on models, I took PVS impressions and poured models. I placed the tibases onto the analogs, and sure enough, I was screwed (see picture #3). What to do?
After much head scratching, I realized I could figure this out. The restorations were going to be screw-retained anyway, so what's wrong with having the tibases occlude with each other (protruding right out the occlusal access holes) after I reduce them? Well, before doing this, I realized that I would have to reduce them too much. There would be very little left to lute to the crowns.
So then I thought, how about using stock abutments? Although I would still have to reduce them a lot occlusally, I would have wider abutments to gain some ferrule with the crowns. Brilliant! I had a Guinness to celebrate (see picture #4). However, they were still too short. But then I noticed that the two stock abutments had 2 mm tall aprons apical to their margins. Aha! A quick call to Implant Direct to order two more abutments with only 1 mm tall aprons solved the problem (picture #5).
Pictures #4 & 5
Now I had decent looking abutments to scan directly in CEREC. I knew the crowns would be short and would require lots of manipulation to get them to look decent, but it worked. I milled the crowns and had to carve out some residual ceramic in the centers for screw access to get things to fit together. I made sure to preserve the flat planes in the crowns that fit against the corresponding flat planes on the abutments. I adjusted occlusion in the blue phase on the models. Picture #6 shows the crowns at this stage. Pictures #7 and 8 show the restorations in the mouth after I luted with Ivoclar Multilink Hybrid Abutment Material. All that remained was sealing the access holes just like we do for all other restorations. In this case some metal is exposed.
Picture #9 shows a bitewing of the final restorations. They've been in the mouth for just two weeks. I was still able to get some teflon tape into the small spaces above the screws. The final two pictures shows the final restorations in the mouth.
Could I have avoided this problem? Yes. Before placing the second implant (#31), careful analysis of my inter-occlusal distance would have alerted me to trouble. My oral surgeon did too good of a job building up the lower ridge. You can see that my lower implant is rather small and short. I could have reduced the bone, placing a longer and deeper implant. Just 2 more mm would have avoided the problem.
I almost went for help to c-docs for this, but I knew I could figure it out on my own. Another problem solved with our great technology with CEREC.
This patient presented with #30 crown fractured off with recurrent decay and the tooth could not be saved. We discussed treatment options, he watched our implant videos on treatment options and possible implant treatment. He elected to have an implant placed. After taking the scan and doing the digital waxup it appeared that we could remove the tooth and place the implant immediately. The roots were short and there was adequate bone. I informed the patient that this was possible if all aspects of the procedure went perfectly, ie if the planets align. If not we would remove the tooth and graft the site and wait. I also did a custom healing abutment which I love in this situation as no sutures were required and it helped keep my graft in place, and started shaping the tissue immediately.
This was a motivated compliant patient that I got very good fixation of the implant. It is not often I do molar immediates but felt this was a very good indication.
I was working up a case referred by a colleague recently and part of the referral, in addition to an implant, was that the patient complained about a chronic dull ache ever since he'd had a tooth extracted a few years ago. A PA from the referring dentist demonstrated that there was a retained root:
Sidexis CBCT image demonstrated it this way:
As I was planning his implant for the number 5 position in Galaxis I was trying to decide what to do about this root tip when it hit me:
I figured there was an accessible path for an osteotomy that would allow access to the root tip, and if I couldn't deliver the fragment I could simply drill through it. I didn't much feel like cutting a huge hole in his palate and risking damaging the vital #3, so I designed a pair of CG2 guides and printed them.
After delivering the implant I accessed the root
I was unsuccessful trying to deliver the root tip intact, so I drilled through it, felt confident that it was obliterated, grafted and closed, and here's the postop:
After using this method for guided implant osteotomies for so many years so successfully, I had every confidence that I would be able to access the root tip and minimize the risk to the adjacent tooth. Guided root extractions.....I love what Sirona technology and a little out of the box thinking can do for our patients!
CEREC gives us a ton of options and allows us to do treatment for patients without the frustration to us as clinicians or frustration to our patients. For me one of those treatments is Maryland Bridges. As we all know, if we attempt to do this with a lab, provisionalization is challenging and we are at the mercy of the lab for getting the shade and fit correct. CADCAM has made this a very efficient and predictable option for us chairside.
This patient has a lot of compromises but really wanted something fixed versus her removable partial to replace #23. As you can see from the radiograph, tooth #24 is not doing well. I had her get a consultation from an endodontist and took a CBCT. He thinks it looks fine and would be a candidate for an abutment but I still think the tooth is toast. I really wanted to avoid potentially opening a bag of worms with #24 and didn't want to prep #22 for full coverage to act as an abutment for a conventional 3 unit FPD.
So after some discussion, I felt a Maryland bridge was the best option. In this case, I did prep a little into the canine a little bit.
Here's the proposal:
Restoration at try-in:
I used a C14 block A2 LT. I did have to re-fire this case a second time for color.
Nothing earth shattering for this case, but I'm still amazed how we can do this in less than a two hour appointment and be ultra conservative and get a great result. I don't know how long this will last (I've been searching on PubMed for articles that Skramy refers to but couldn't find them), but with total etch and enamel bond, I think it will do well for quite some time.
So I got myself scanned by my wife's assistant and created a night guard out of nextdent's ortho clear. Took 39 mins to print on the moonray S. Working on profiles for form 2 when I get more resin in. Fit was perfect.
I want to share this case that came in today to demonstrate the evolution in thinking I've gone through over the past several years. This patient came in because the bonding on his #10 chipped off and he wanted it repaired.
A few years ago I would have most likely sat him down and repaired the bonding on his tooth and gone on with the rest of my day. But today I used the knowledge I learned by taking all the Spear Seminars and Workshops over the years. I asked questions to determine his value system, learned more about his history and what his ultimate goals are. I used CEREC to take a full mouth ortho scan in a few minutes to instantly show him his teeth and what the possibilities were.
Combined with photography, he had a clear understanding of what could be done and decided to proceed with a diagnostic waxup that will help us further continue planning this case.
By seeing the forest through the trees, I took a mundane, direct restorative case and converted it into an emotional, full mouth rehab case.
"You don't know what you don't know"
Pt contacted the office today at 2pm and reported a broken front tooth. Crown and RCT completed years ago, not by me. Occlusion was evaluated and, with the remaining tooth structure, I felt enough ferrule could be gained to place a post/core, crown. At 78 years old, her main concern was church tonight and how she couldn't bear to be seen (it's Wed in the South, ya'll). With the hx of RCT, no anesthetic was necessary. Cord packed, post/core, prep. CEREC images. Design, mill Empress A2 Multi. Bond in with RelyX Ultimate. I know immediate before/after pics aren't the best for presentations, but I think in this case it highlights the power of what we can do. While I love implants and guided surgeries, having the ability to replace a front tooth in under 2 hours still blows my mind after 7 years with CEREC. It may not be guided surgery or printing sexy/cool, but it's bread and butter dentistry that pt's truly appreciate.