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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 ;)
Its that time of the year where work and family time all blend into one. Its the time where we take a step back and look at the landscape and realize that there is more to life than margins or margin thickness.
12 years ago we started this website with a dream, a dream to help the CEREC community. While a lot has changed in 12 years, including the distributors, the blocks, the software, the people, what has not changed is my sense of gratitude to the CEREC community that has allowed me to turn my dream into a career.
Im grateful for my friends Mark and Mike and all the others that carry me when Im down. Im grateful for my incredible team that works behind the scenes to make the rest of us look good.
Im grateful to all of you that through thick and thin have trusted us with your well being to provide you with whatever little knowledge and information we are able to share. We are honored to be given that responsibility and we do not take it lightly.
Most importantly Im grateful for my family. Next Tuesday my wife and celebrate 20 years of marriage. It seemed like yesterday I was trying to convince her to go out with me.
Life has its ups and downs but this is a time of year to look around and be grateful. There are so many in the world that do not have the resources that we are all blessed with. The next time your margin doesnt quite mill just right, or the milling unit doesnt communicate with your Speedfire, just take a moment and realize that things could be so much worse.
Thank you all for making this community great. All the incredible contributors who give selflessly to help other CEREC owners. May you all have an incredible and happy thanksgiving holiday!
When is it worth it to mill out fillings vs doing them direct? Honestly, I would be happy to mill out every filling. To not have to place another matrix band or push a wedge into unsuspecting gums and watch patients flinch (because I am sooooo strong)... it sounds amazing. It's not my reality however for several reasons: a) sometimes I can be more conservative placing a direct filling and b) cost plays a factor. One block that costs around $30 averages 4.6 comps of 3M Ultra Filtek composite. If I can mill out 2 restorations out of one block obviously that is half of that. I don't often do fillings that are that big, but there are times that it really does pay off do mill out an indirect composite- even if I still bill it as a composite filling at PPO fees. Here is one them:
Here is a prep that has a large buccal/lingual width and the distal half of the tooth has a heart shape that doesn't adapt well to matrix bands. He had that frustrating decalcifcation ring that that kept making my proximal box larger and larger.
Make sure the walls converge. This design takes minutes. It's so fast!
Bonding this in has amazing contacts that are controlled instead of leaving an open contact or point contact that wedges in food.
This was just one of those cases that was successful because I milled it and I am so happy that I own a CEREC. I used a 3M z100 block and billed it as a composite. I had total control over the contacts and the margins (not that I am a control freak or anything). There are no voids in the large fill... I easily could have used Cerasmart, Enamic or Lava Ultimate too.
Do you mill out your filings? Why or why not???
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!