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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.
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.
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.
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.
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.
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.
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.
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
After rough prepping the teeth, we transferred the waxup to the mouth and then did final depth reduction
Here are the final preparations:
And here is the final result. Vita Mk II 1M1
Just wanted to show this screen shot of the lower image I took today. Pt had perio surgery on 18 and I removed her old crown, the recurrent decay, and was prepping for a new one. How the hell would someone get an impression tray on this pt?? Her tori were just humongous and there was no room for a tray there. She was so happy to not have that issue with the tray cutting her and tearing up her tissue. I was just happy to easily be able to image the lower so easily as if those damn things were not even there. One of the hundreds of reasons that digital is so much better than analog!
I have a patient that wants to do upper 8 and lower 6. My questions is how would you prep/bond the canines but more importantly the first premolars? The gingival margin will be on root surface. Those teeth are completely virgin.
1) Normal veneer prep and bond
2) full prep and cement with rmgi (lots of extra tooth removed)
Would love to see differing view points and the reason for each?
After a great trip to Sirona/Atlantis in Boston I thought I would post a case I did.
#14 failing molar, extracted and grafted site, guided implant surgery with a crestal sinus lift, planned for with Cerec Guide2. After healing we scanned with the FLO scan body and sent it to Altantis. After the abutment design was approved I recieved the file to make the EMax crown here and 2 days later the abutment showed up with seating tool. Don't forget the seating tool its great.
Great work flow, very little stress, If you do not feel comfortable designing custom abutments this is the way to go. Also for situations where a TiBase is not a good solution.
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Another convenient benefit: the ability to custom color zirconia restorations prior to sintering, while also creating fine shade tones quickly and easily. Colors can also be leveraged to adjust intensity and characterization. A complete range of shade options is available, including a combination of basic and additional shades that enable individual reproduction of the entire range of VITA shades. VITA ZIRCONIA YZ HT SHADE LIQUIDs are available in seven VITA classical A1-D4 shades and seven VITA SYSTEM 3D-MASTER shades, as well as supplementary shades for gingival, cervical and incisal areas.
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Thanks to the CEREC, fabricating and delivering multiple implant restorations is a very easy process. This case was seated yesterday. I extracted and grafted the area and let the area heal, placed the implants using a guide and restored with screw-retained restorations. The delivery took 15 minutes with no adjustments.
Implants = Astra TX 3.5x13mm
Guide = Optiguide (pt has lots of previous restorations causing scatter)
Restorations = B1 eMax LT
The cost savings for implant restorations is not only in lab expenses, but also the delivery time, especially when you are dealing with multiple units. If you aren't restoring implants with your CEREC, you're missing out!!! Go take L3 at Spear!
Happy Friday all,
And GO Dawgs!!!!
Wanted to post this case we did right before the holidays. Patient presented to the office with a failing filling we had done about 2 years ago. At that time I had informed her that it would be a temporary fix due to size of the restoration and how much tooth structure destruction the decay had caused. When she presented the composite had debonded and informed her it was time for full coverage. She has several other issues going on, but she is a "come in when something hurts or breaks patient." I find that with CEREC we can treat these patients on the same day and give them what they want (single visit emergency treatment) since she is not seeking comprehensive treatment.
Since the facial surface of the tooth is in decent shape, meaning I can copy the line angles, it gives me a great starting point for contouring. Biocopy in 4.5.2 has be great so I have been using it more and more in these scenarios. There is a lot less design time for me in these instances.
Preop Condition showing failing composites on mesial and distal:
Shade selection: when I'm looking at teeth I try and look at surrounding teeth and contralateral tooth. I see 3 clear zones in the teeth with a significant area of translucency at the incisal. Vita Triluxe and eMax would be on the list for my choices. You could use empress multi, but I think all of us have favorite materials for anteriors. Vita Triluxe 2M1 selected.
Preparation was very conservative trying to follow 3 plane reduction. Also, if find sometimes dentists will not prep subgingival at the interproximal areas. If you want to get good emergence in my opinion you have to do this. Now there are a lot of factors: bone level, tissue health, spacing, etc... But keeping the prep above the tissue in these areas will not create a great emergence.
Immediate Delivery. Don't worry tissue will fill it. As Mike says, biology will win. My assistant did all the characterization. I still like to do the contouring, prepolishing, and post polishing. I thought she went a little too much with the white but it turned out great I think.
Final Pics After 8 days showing great tissue response:
Overall good outcome. I know I missed that mesial line angle. Saw it after I was loading the photos. Best advice that was given to me was to take photos of cases if you want to improve. You will see so much that you don't catch in that moment.
Everyone Stay Warm.....
Oh, and did I say GOOOOOOOO Dawgs!!!!!! My heart finally recovered after Monday, ready to go now....
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!