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Not too long ago my "CEREC assistant" moved to sunny California. I was happy for her on a personal level, but sad to see her go. She had worked with me for 8 years and she blossomed in her CEREC knowledge and training. Now I have had to refocus on training my other assistants and so I decided to make some easy flow charts for my lab to help out. If these can help anyone here than feel free to use them! PDF versions are printable.
Nothing fancy here. Typical case. Pt appointed for #2, #3, #15 direct resins and #5 crown. We scheduled 2 hrs and finished ahead of time; just over 1:30 (#5 Empress polish only; no oven time). I hope the following tips help you leverage your CEREC and complete more treatment in the same amount of time.
1. Anesthesia of upper right quad only. Next capture pre-op images of arch as I wanted to copy the B cusp of #5. Also image opposing arch.
2. Teeth #2,3 & 5 prepared. *Note that I did not spend time restoring the molars. As soon as the images were captured and we advanced to the model screen, anesthesia was delivered for #15.
3. You can use pre-op images to check your reduction if you're not using reduction burs or bite tabs.
4. Copy line of #5 that avoids the DO resin, hole in the occlusal surface & abfraction.
5. Initial proposal.
6. Overlaying images of pre-op and CEREC proposal.
7. Final design of #5 with unrestored #2,3.
*While the CEREC was moving from AQUISITION to MODEL phase, anesthesia was delivered for #15. No 'downtime' waiting for CEREC to process models.
*While #5 was milling, #2, 3 were restored and #15 was prepared for a direct resin (OL).
*Leaving #2,3 unrestored during imaging of #5 allowed me to disregard them when designing occlusal contact strength of #5 crown.
*After restoring the molars, I could adjust the occlusion of #2,3 while #5 was milling. Without the crown in place, I could disregard occlusion of #5 prep as there was none.
*After delivering #5 and cleaning the area, #15 was restored. As the upper right had already been restored/contacts adjusted and polished, I only had to concentrate on #15 when adjusting the composite.
Again, this isn't 'sexy,' just everyday bread and butter dentistry. My hope is that you'll find all the little areas of 'downtime' during a crown appt and find that there is plenty of time to complete other dentistry and make the appointment more productive while not increasing chair time.
We have slowly but surely increasing our Sleep Appliance "practice within a practice", and I wanted to post a case and find out how many of you are doing OptiSleep as well as hear how we can all work together to make it better.
So far, our cases have done very well, and the patients love them. We still do a few non Optisleep appliances due to limitations in the system, but the Optisleep appliances fit so much better than anything on a model based system I only want to do those.
Here's a case I sent out today that we recently scanned:
Make sure to take time to send the scan to BeamReaders or make your own chart notes about what you see in the imaging. Here, we see arrows pointing to some potential (asymptomatic) condylar "bird beak" type of deformity on the anterior part of the condyle. We'll keep an eye on this. There is also an engorged nasal concha as well as a slightly deviated septum. We recommended that she use Flonase (OTC now) and see an ENT if she has persistent sinus pain or fullness, or nasal congestion. Everyone wants to go right to the narrowed airway, which is fine, be make sure you document anything else you see. If you have any quick questions, please post a screenshot and I, or even better, TK will give you some advice.
Here's just the pre treatment Sicat Air screen. Significant airway constriction in the oropharynx, and no nasopharyngeal or hypopharyngeal issues. Make sure that they position their tongues down and somewhat back to better approximate where the tongue would be while they're sleeping.
Then comes the George gauge. We set everyone at 60% of maximum protrusion. When we have Zephyr we'll make it custom, but for now we're trying to be consistent, and patients are tolerating it well so far. Please make sure you have 5mm of space between the arches, or you'll get the naughty note from the Sicat techs, since less than 5mm gives them insufficient room to make the appliance. With this in place, we take a new CBCT, and here we tell them to keep their tongue forward as will happen when you move the mandible (and the genial tubercle) forward. You can see that we got significant improvement in the airway space. I will say that there isn't always a huge red to green transformation, which worried us at first, but we've had great consistent clinical feedback from the patients as to how well they're sleeping so we worry less.
Hopefully some of you will post about your SicatAir experiences. We're hardly experts, but we keep on trying to get a better and smoother workflow.
My Cerec journey began on June 5th when everything was installed at my office. Since then I have completed 23 Cerec restorations. I’ve learned a lot with each restoration. I’ve been waiting for one to be near perfect that I’m really proud of to post on here but none have met that criteria for me yet. I decided to make a collage of them all and post them together, the good, the bad the ugly. The one thing I can say about all of them is the margins were all BEAUTIFUL on the pre-op and post-op x-rays. So as much as I am down on myself for some parts of a lot of these preps in the end clinically they were all as good as or better than what I was getting from the lab as far as fit and margins.
What I learned so far:
-Early I tried to do too many things at once, 1st patient I did a DOL Onlay on #3 and #4 attempted a MODL Onlay on #4, then decided I would try my first crownlay and not do a build up and try to smooth everything and make it flow together. In the end it resulted in overmilling because without doing a build up I had “points” that could only be smoothed out by taking away what little palatal and buccal tooth structure I had left....
-In fact I tried to do the same thing on my next crown and decided I was trying to do too many new things at once while also learning my way around cerec. Decided I was going to stick to my old tool belt, build up and crowns and make them more smooth, rounded, flowing, and high & dry when possible
-I was shocked on my first few preps at the “roughness” of my margins, even before Cerec I would go over my margins with a fine diamond to smooth things out. I use Two Striper Modified Shoulder 018 coarse followed by fine. What surprised me is that I what looks smooth to my eyes looks different on the computer. Some of this is real minor roughness and some of the roughness I’m exaggerating, basically I thought what was glass smooth to my eyes was rough on the computer. All I have done to fix it is to take my fine diamond around a little slower and with a little more pressure, sort of feeling the bur level everything (when possible, patients and clinical situations aren’t always amenable to tinkering and refining, sometimes you just have to go with what you can).
-What bugs me is I still can’t see the difference in the mouth of the smoothness of my margins, I just make sure I make concerted effort to smooth them with purpose with my fine diamond, generally it works out but sometimes I’m still stumped at rough spots that show up after scanning, maybe I need to bump up from 2.5X to 3.5 or 4.5X…….
-I have always heard most dentists under-reduce. I have been using reduction burs the last year. I use a 1.5mm reduction bur through the occlusal groove and 2-3 grooves through the buccal and lingual (classic). I switched over to the meissingers two months ago. What surprised me is how often I am under-reduced even using this method. More often its on the cuspal inclines and I think I wasn’t “tilting” the reduction bur when connecting to the occlusal groove reduction. I still have this fear of pulping a tooth by reducing too much and I still don’t have the stones for the 2mm reduction bur. I have some preps that I feel like are almost 1/3rd the size of the adjacent tooth and think “no way I don’t have enough reduction” and sure enough either I barely have the 1.2mm required for e. max or I just decide I am not re-prepping and rescanning and I will just reduce the opposing. Most of the time its on molars. Which makes wonder how are people doing crownlays on molars? I think its bad luck with case selection, 2nd molars and under-erupted 1st molars, time will tell, moving forward I have been connecting the occlusal groove reduction to the buccal-lingual reductions by laying my 1.6mm diamond cylinder on its side, make sure its completely “sunk” and reducing mesial-distal
-Onalys and inlays are still tough, not as excited about them as I used to be. Feeling like if its not a very conservative onlay, I’d rather do a crown. Part of this is a have very well eductated patient baser. I got some patients jazzed about onlays because of tooth conservation and during the some of the preps wasted too much time trying to stay conservative and woul decide a little late in the prep design game to go full coverage. This would make for some long appointments. This was early on and I’ve developed a better eye for what will be good for an onlay vs a crown. Oh, and cerasmart is awesome!
All in all I did 11 e. max crowns, 3 zirconia crowns, 1 katana crown, 1 zirconia bridge (forgot to screen shot it so I put in the BW) and the rest cerasmart inlays/onlays
I can look at each of these and tell you something I seriously don’t like about each of the preps, some worse than others, either way, here they are... I am registered for level 2 beginning of August, maybe I'll see some of you there
I know others have posted different techniques using other softwares to execute Essix retainers. I don't think anyone has done it the way that I have though, so I thought I would share...
If you have heard me speak about my feelings on 3D printing, I love it.... BUT, I will not completely love it until I can be 100% digital for all procedures. Now theoretically you can do that now, but I want it to be efficient. That is, I currently mostly print models and guides for esthetics and implants. What I want is to be able to handle everything from bleach trays to essix retainers, etc... I basically want to eliminate all impression materials completely from my office. For this, 3D printing needs to be fast and also a bit more automated I believe. Once that is the case, I would certainly be willing to pay more for a 3D printer if it had more applications like this.
So.. here is a case I did with the inLab software. I know that most of you do not have the inlab software (in US), but it gives you an idea of the possibilities that hopefully we will see at some point.
Patient missing tooth #26. Has been wearing an essix retainer long term that he broke.
Scanned with the Omnicam:
Exported .stl high resolution and loaded into inLab 18. From there, designed a crown in the space:
After design, virtually seated and added a base to it:
3D printed it in grey resin (100 microns Z)
Block out undercuts and used Ministar and 1mm Clear Splint Biocryl :
Now, the best part... go into inlab 18 software, reverse the virtual seat and choose the original layer, export the .dxd file, import into CEREC and then mill the tooth (composite block). Then insert it into the Essix...done.
There may be cheaper ways to do this, but this was super easy and my guess is that it will be very predictable. That is what is important to me.
I live in a college town so I see a lot of college students who end up having a bit too much fun on a Friday night and experience dental trauma. This patient presented with crown fractures of #8 and #9 with the pulp of #8 evident but not obviously exposed and #9 pinpoint pulp exposure.
Of course, she is about to head home for summer break so I won't be able to do any follow up for the next ~3 months.
I used a bioceramic for a pulp cap of #9 and then I prepared the teeth for crowns as conservatively as possible (especially on the lingual leaving the cingulum intact) and milled crowns out of Empress Multi to be used as provisionals. My rationale for cementing these as provisionals rather than definitively is in case either of the teeth become discolored or need RCT.
I plan to see her back in the Fall to evaluate and proceed with the final restorations.
Would anyone do this differently if they were in my shoes?
Are you quadrant CERECing? The single CEREC restoration is a very productive and profitable procedure in our practices. But, the profitability increases exponentially when we begin to perform a quadrant of CEREC restorations or treat additional restorative needs during the same appointment.
In my practice, a single-unit CEREC restoration that is fired may take around 1.5-2 hours depending on the case, but adding an additional CEREC restoration only adds about 30 minutes to the overall appointment time while doubling the production. In other cases where a patient only needs a single-unit CEREC restoration while needing direct composites, the appointment time may not change since the milling and firing times can be leveraged.
Here is an example of a quadrant CEREC case I completed last week. This 80 year-old patient had decay on #21 and #22 (not pictured) and failing restorations on #28, #29 and #30. The treatment plan included: #21 MOD composite (not pictured), #22 DIFL composite (not pictured), #28 DO composite, #29 full-coverage crown and #30 full-coverage crown. Emax LT, shade A4 was used to restore #29 and #30 although I could have used a C or D shade if I had it. The entire procedure took 2 hours and 20 minutes and produced around $2800.
Here is the overall timeline detailing my role and my assistant's role for this particular procedure.
Always scan the teeth past the midline to the contralateral central for the best proposals with regards to anatomy, contours and marginal ridge heights.
When treating 2 or more teeth with the CEREC, make sure to marginate all the preps before moving forward and always double check that you've marginated the correct tooth.
Once the CEREC proposes the restorations, choose the restoration that is closest to being finished with regards to design. That way, it is sent to the mill as soon as possible and the next restoration can be designed. For this case, in my opinion, #30 appeared to require less design work, so I started with this crown first and sent it to the mill.
After the first restoration's design is finished and sent to the mill, begin designing on the second restoration to leverage the milling time.
Here is the final design of both restorations.
The restorations were tried-in after milling to make any adjustments to the contacts.
Here is the final photo of the restorations bonded and delivered.
There are many different ways to be efficient when treating a quadrant of CEREC restorations such as having an extra milling unit, delegating aspects of the CEREC workflow to the assistant, treating additional restorative needs, using the Ghost Contact Technique, etc. If you've been intimidated to use the CEREC for multiple units, set a timeline with your team outlining what you will be doing, what your assistant will be doing, if any hygiene checks are needed, etc. Level 4 also teaches how to be efficient with quadrant CEREC dentistry.
This is one of those cases that is just so much easier because of my CEREC.
Pt comes into my office with large existing amalgam restoration on #31. She has recurrent decay around the entire lingual margin of the amalgam restoration. If I didn't have my CEREC and the ability to use Biocopy this could be a difficult appointment.
I anesthetize the pt and my assistant scans the case into the Biocopy catalog. She then copies the information into the Lower Jaw catalog. In the Lower Jaw catalog, she uses the Cut tool to remove #31.
I prep #31 for partial coverage restoration. I know there will be multiple opinions on whether full coverage or partial coverage should be used here and also on material.
Personally, in this case I prefer partial coverage and also prefer GC Cerasmart for restoration. This pt is 87 years old, in an assisted living facility, and Im not sure how often the partial is removed, despite our pleas. If I used a material such as e.Max and she returned in the future with recurrent decay, the entire restoration would have to be removed. With a material like Cerasmart, it can be repaired intraorally with a direct composite.
Start to finish she was in our office for just under one hour. She left with a big smile, not having to go without her partial while a restoration was fabricated at a lab!
So I have been working on this case for just over a month and delivered it today. Patient had CC of misaligned teeth and failing composites. Declined ortho, don't blame her she is 71. However, she was made aware of how much I was planning to "pull back" her teeth based on our waxup and how everything overalyed with CEREC. So again, here is how I used our technology and software to our advantage.
I scanned the patient with the 4.5.2 software and exported the STL files. They were sent along with photos via dropbox to my lab with instructions on the case.
We received the mockup back as an STL file and printed using Form Lab 2 printer.
I opened her case back up and then scanned the digital waxup and overalyed to show the patient at her consult. After she agreed with proceeded with the case.
We rough prepped the teeth and delivered the mockup to the mouth, using it as a reduction guide for the case.
When I tried to deliver the bisacryl temps, I nor the patient liked the midline, it was slightly off. So I used the digital model and editted the design and milled out Lava Ultimate temps. This is how tissue presented after 2 weeks.
After approval of the provisionals, we printed her prepped arch and milled 4 vita mark 2 crowns. Here is the following lab process:
These were delivered today. So we will get the patient back in a week or two for finals. But really thrilled with the outcome. I didn't see the "junk" until after the photos .
These types of cases have become very predictable in my office. From sending it digitally to the lab and visually seeing how much we are removing, to having a model ready for fine tuning the restorations, I think 3D printing is taking a big part of our digital dentistry arsenal.
Here is a design tip I like to use when working on anterior cases. I always take a pre-op Biocopy image of the existing condition even if I'm not copying it direclty. I designate the case as Biogeneric individual and then add a Biocopy catalog in Acquisiton.
From there, I can use the Biocopy overlay to help determine my midline and incisal edge position. We've taught this before at our workshops, but I'm using another feature to help show the patient a nice before/after prior to milling.
In the design phase I will group the restorations together.
Next I can turn OFF the upper jaw catalog in Display Objects and turn ON my biocopy.
Now to give the patient a nice before/after view I simply toggle on/off the Restoration button in Display Objects to alternate between pre-op and design.