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The following patient was dissatisfied with her previous cosmetic result delivered elsewhere, so we literally went back to the digital drawing board to re-design her smile. One of the most impactful concepts we teach at Spear Education is understanding that a smile usually consists of more than just a couple restorations. We use templates and mock-ups to demonstrate to the patient the potential solutions to his/her concerns, to help him/her understand what is possible, to set realistic expectations of the outcome, and, of course, to guide our Cerec design.
Good morning everyone,
Having a pediatric dentist working side by side in our office allows me to see and treat cases that can be somewhat challenging. This young man (14 years young) presented this morning having taken an elbow to the mouth during a basketball game. He indicated that the tooth was loose but was not having any pain. As you can see by the attached radiograph, we have a serious root fracture. I am also attaching a photo of his current occlusion, which also is mess at this time. . Today, we splinted the teeth together so the patient would not lose the coronal portion of his tooth, as we work on his treatment options. Our ultimate goal is to preserve his ridge as best as possible for future implant placement. Our initial thought is to endo the remaining apical root to keep this asymptomatic and preserve the ridge until he is old enough for implant placement. We feel there is not enough apical root left to extrude and support a crown restoration. If we extract everything, our concerns are loss of supportive bone levels, considering he wont be a candidate for implant therapy for quite sometime.
If someone has other options, would be great to hear them.
I saw a comment on the boards the other day that asked this question. It was funny because I am going through a case right now that I had some issues with this.
I don't exactly know how to answer the question to be honest. There are many different things i've heard.... things like the blanching goes away in 20 min or less,etc... The way that I have done it in the past was just by "feel". That is... I want to put pressure on the tissue and I can usually feel if it's too much by how it seats. If I have trouble, then I will adjust. It also will depend on anterior vs posterior and how much tissue I need to move.
Here is a case replacing 2 congenitally missing lateral incisors. He has been wearing a flipper for over 10 years and finally wanted some teeth. Here is the initial preop photo...
After doing the plan, we placed the implants guided in the site
I let heal about 3 months. Since he had a flipper, I just used healing caps that were flush with the tissue and adjusted his flipper for the provisional.
Here is how the tissue looked at full healing:
As you can see, I have a lot of tissue to move, especially on tooth #10. Now, here is the mistake that I made. I tried to move it too quickly. Meaning, I pushed on the tissue way way too hard. It was difficult and painful for the patient (I did not numb up). #7 was still painful, but not that bad because I didn't have to go as far...
Here are the initial provisionals:
How do I know I pushed too much too fast? Here is an iphone picture my assistant sent me two days later (it's her brother in law)
Yikes.... I had to have the patient in immediately, get the provisional out, recontour it quite a bit and put it back in. That with a chlorohexidine rinse healed the problem in about 4 days.... Here he is as of Monday:
So.. be careful. If you need to move the tissue a lot, do it in a couple stages and not all at once. You may get lucky and it will work... or you may end up having a significant issue like I did on this case.
Just another case with another custom healing abutment. It is aour standard protocol now in most cases. I am doing a presentation this week so I figured I would post this. The final crown was made from the initial scan at the time of surgery. I literally removed the healing abutment and placed the crown. Also the bone was profiled at the time of surgery
Comparison of the gingival 1/3 of the custom healing abutment and final crown
I think there is definitely a case to be made for some sort of study on this. How much is too much, how much is too little and what is just right for each different clinical scenario.
While we strive to be complete in our care, we also want to be efficient. These are just questions that come to mind that I would love answered.
I had my Form 2 printer delivered last week and it's been so much fun playing with it. This patient presented with fractured teeth @ #20 and #21 with missing 18,19. We decided on a plan to extract the roots 20 and 21, place implants @ #19 & #21 and make a 3 unit bridge. In the past, I would have sent for a Sicat guide or made 2 CG2's, but I want to go over the workflow for a printed guide since I have a new toy.
First, the patient (or a model in this case) is scanned with CEREC and a bridge designed so that I can incorporate my plan into Galaxis with one .ssi file.
The implants are planned in the usual way, including setting D2 and choosing a CG2 sleeve. The CMG.DXD file is then exported in the same way as you would for milling a guide. Since I don't have inlab, I sent this file via dropbox to Frankie at AA Dental and in a day, he converted my file to a .STL file.
In the preform software that comes with the printer, I was able to add supports so that it prints properly (these can be edited away from critical areas).
Once the supports are removes (kind like the sprues on a milled guide), the guide was tried on the model. It really is very easy to remove them.
This entire process took a day and cost about $20 for the stl conversion and about $7 in material. Just another option with a pretty easy workflow. It's also fun to play with!
All you can do is save still shots as .jpg files and post them here.
I wanted to share my experience from some of these larger cases I have completed recently. First off, Level 4 was a huge help and I cannot give that course enough credit. Sam, Mike, and Mark do a great job updating the content and making sure to cover as much as possible. Everytime I mentor a Level 4 course I pick up something new that I can use when I get back to the office.
I took photos throughout the process, but don't want to overload with too many on this thread. What I did want to point out was how the process of Cerec and milling gets you about 80 % there. The mill likes to mill rounded angles so even with copying the waxup/mockup you will still have some work to do post milling. The models were ordered by exporting the case after margination as a .dxd file. Upload to Infinident and they will send nice solid models as well as trimmed models in about 3-4 days. Cost about $25. They can also send an opposing. Most of these cases I'll rely on the biocopy and never order the opposing.
Tips to make this process flow:
1. Get a good waxup from your lab. Most of the time they will waxup in grey or blue to allow contours to pop. A siltec stint or any putty stint should be made as well.
2. Transfer that to the mouth. I dont like trying to stitch the preps in the mouth to a waxup off a model. Have the patient work out the occlusion and copy that for your biocopy.
3. Any teeth more than 2, I do in 2 visits. Its just too stressful for me. Order a model and work on your own time.
4. Contour and prepolish then crystalize. (obviously if using Emax)
5. Then add characteristics with stains and fire. Finally glaze. If I separate these steps it just helps visualize the outcomes.
Preop Situation. Patient wanted spaces closed and new partials made to allow her to eat. Ortho was declined even though at a young 78 she probably could have done it. Emax A2 MT
Test Drive. She wore these for about 3 weeks. Had to adjust occlusion once.
Initial Milled Models crowns on models from Infinident
Contouring and Prepolish. Used all burs from Cerec Doctors Kit
Stain and Glaze:
Several old restorations needed attention. Patient's OH is unfortunately not as good, but he is improving. His dexterity is not great due to medical condition. Electric tooth brush hopefully will help him. Posterior teeth were not built out to fill buccal corridor because he did not want to redo his LPD. So had to compromise. Also, had to compromise with him on shade. I did not want to go that white. Emax MT A1
Hopefully this shows how important these post milling steps are. Do yourself a favor and if you really want to start doing some anteriors, check in to Level 4, totally worth your time.
My last case depicted lots of compromises, this one was much easier. The patient came in reporting that #7 had broken off at the gum line, and she super glued it back in... not too shabby.
#7 was atraumatically extracted and implant placed immediately.
A Zirconia abutment was milled and infiltrated with shade 2-m-2.
Final post op. with stained Celtra Duo crown.
Quadrant dentistry is fairly predictable. You take a quadrant scan, take a buccal bite, design your crown, adjust your occlusion on the CEREC software, deliver your restoration and boom, everything is good.
Where we start to doubt this process is for larger scans. Full arch scans that everyone has taken result in inconsistent occlusion. You take the buccal bite on the right side, the occlusion is heavy on the right side and the left side is wide open. Conversely, you take the bite on the left side and the right side is wide open.
So you take a larger buccal bite and hope that corrects the problem. Well, not really as you can see from the screen shot below:
So how do we improve on this? Is it where you take the buccal bite? Or is it something else? We decided to do some investigation and see if there were steps we could take to get the occlusion and the models- as accurate as possible. I would love to hear your comments and feedback on the situation.