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I thought I would take a moment to go back to the basics of design... I was reminded about this as my associate left for maternity leave and my life at the office has gotten a little hectic. At the same time I have a new team member whom I am trying to train on the Cerec but there is just never enough time during the day so I created a "cheat sheet" that she could keep near the Cerec as a reminder.
My practice is run on efficiency. I want optimal results in the optimal amount of time. To do this we have to have systems. It's so easy to get off track in all of the nuances of the software with so many tools to play with- tools which I do use, but for 85% of my cases, I want a simple recipe for myself and team members to follow. Here is my "cheat sheet" listed and in printable form if you would like to use it for your own team members:
Remember F.O.C.C - Formation Of a Cerec Crown
- Select “Ctrl D” and move cursor around to show cursor detail box.
- Select Shape Tool > Anatomical, 2-D > highlight the internal portion of the crown.
- Left click & hold, track ball up to lift the height of the fissure.
- Let go of click and see where new fissure height is in the cursor detail box.
- You can either use Form Tool or Shape Tool to reduce occlusal interferences. The goal is to have royal blue occlusal contacts.
- Form Tool > Remove > make sure the orange diameter is slightly bigger than the interference and either left click, or hold left click and move cursor around.
- Select Shape Tool > Circular, 2-D.
- Make sure arrow is pointed in the direction that you want to change, left click & Hold, track ball in that direction.
- Select Display Objects > Trimmed Model
- Form Tool > Smooth and either left click, or hold left click and move cursor around as if you were painting that spot.
- Remember that smooth tool will only flatten so if your adjacent contact is convex, you will either have to adjust that contact in the mouth or use the remove tool to get a proper contact.
I started to remove decay and was down to the level of the bone.
Thought it would be interesting to see a side by side of Bruxzir (done at Glidewell) vs an infiltrated CEREC Zirconia. Both are still quite opaque, but making progress.
This was the original situation in 2013:
I did 4 and 5 with Bruxzir and we did #3 with CEREC Zirconia
This case was one of the most challenging esthetic and structural situations I've ever been faced with. We knew going into this case that it was going to fall far short of ideal because of the poor position surrounding the existing implant #9. It was an old Calcitek implant that was placed far too deep and much too far buccally. We made the easy decision to bury the implant in favor of a FPD #8-9-10 and have the periodontist perform hard and soft tissue grafting to gain as much bulk as possible in the ovate pontic #9 site. Here's what he was able to accomplish:
As you can see, even after extensive grafting there was still a considerable vertical defect remaining. So I made a mid-crestal incision and used pressure from the ovate pontic to push the tissue as far facially as I could. We were still quite deficient, so I then injected Juvederm hyaluronic acid filler into the papillae and facial tissue to shape it around the provisional bridge contours. Next, I had to deal with the very dark stump (ND9 prep shade) on endo-treated #8, so internal bleaching was performed using sodium perborate. This took the stump shade from ND9 to ND3, making the difficult block-out much more manageable...
The next challenge was to match the very translucent enamel on her natural teeth with the e.max LT bridge block. To attempt to accomplish this, I milled an LT BL2 block and layered lavender stains first, followed by some brown chroma, and finished with a white-wash to match her striated enamel. After several layers of stain/glaze characterization, we ended up with approximately B1 as a final ceramic shade. It's not perfect, but here are the before and after shots:
After struggling with every aspect of this restoration, the biggest take-home message I learned was: once the soft tissue becomes deficient, it's very hard to recover and create a truly natural look. The papillae loss meant we would never have a biomimetic result, but we pulled out all the tricks to make it as natural-looking as we could. I'm honestly just very happy to have this one finally completed, even with it's shortcomings.
The answer is that I don't know yet... just messing around with some fluorescent infiltration with the abutments... can get the abutment to really fluoresce like natural dentin. If you use a translucent veneering structure like e.max HT... You may get a more vital restoration. Interesting stuff!
Rich Rosenblatt did a great post about the articulator function and using it when doing implant crowns. Here is the link: https://www.cerecdoctors.com/discussion-boards/view/id/53970
It got me thinking about something I have been doing regularly.
About 8-9 months go I started a little experiment in my office. I started using the articulator function that is built into the software. My reason for doing this was two fold. First I wanted to see how accurate the articulator is and also to see if it would reduce my post op adjustment.
As a lot of us have come to realize e.max does not mark very well with articulating paper. That coupled with a numb patient make it hard to see excursive interferences. The topic of post op sensitivity with e.max comes up pretty regularly on the cerecdoctors.com boards and inevitably, after the recommendation of checking the occlusion for interferences, the sensitivity goes away after adjusting. This got me thinking about using the articulator to find these problem areas so that we wouldn't have to have the patient calling back with post op sensitivity and needing an adjustment.
This is also an advantage when dealing with zirconia. Adjusting zirconia is not only difficult but also it is imperative that the zirconia gets brought back to a good polish to prevent wear on the opposing dentition. So the less we have to adjust the better, especially since we can't try it in until it after it is sintered.
Here is a case that shows the use of the articulator. This patient has an anterior open bite and group function. If we did not take into account the excursive movements then the chance of an interference is high. Which of course will lead to a need for post op adjustments and more chair time.
This first step is to make sure the articulator is active. This is done by going to Configuration->Pptions->Articulator and checking the active button under use articulator. I do not use the articulator to get my proposal, I just have it active to be able to use the articulator. Once this is done any case you open up will be able to have the articulator turned on. This is done in the Administration phase.
To use the articulator function and have it be accurate you need to image to the canine. Which is what I did until recently. Now that it is advantageous to image to the mid-line, I go ahead and image to the contra-lateral canine. This helps set the model axis by making it easier to set the curve of Spee and Wilson. This will give us a better initial proposal and sets the articulator up properly for the best result.
Once the initial proposal is given the distal marginal ridge is slightly lower than ideal.
This is quickly adjusted by using the 4 Direction Anatomical Shape tool. This ends up raising the occlusion to much and needs to be adjusted.
Once adjusted the proposal looks pretty good and should be ready for the milling chamber.
However if we turn on the occlusal compass we can see where we will have interferences that will lead to post opertative sensitivity. The Occlusal Compass is found under the Articulator menu.
Once the compass is turned on you will see the areas that are hitting in the various movements. You can turn of each of the various interferences to see which ones are present and which are not. Then use whichever tool best fits to make the appropriate adjustment. In this case the 2 directional circular shape tool is used to reduce the height of the cusp.
This gets rid of all the excursive interferences. The compass is turned off and the regular occlusal map is visible again.
As I stated earlier I started doing this about 8-9 months ago and have seen a drastic decrease in post op adjustments and sensitivity. By using the articulator to reduce the amount of interferences you can decrease the number of post op visits and occurrence of sensitivity for your patients.
The long and the short of it is use the articulator function for better results on every type of case.
I feel the integration of cone beam CT and the CEREC technology is one of the most amazing things available in dentistry...there is very little that enhances the patient experience more than getting to see the level of detail we go to in order to ensure that they receive the best possible treatment. I had the pleasure of presenting at Patterson's Technology Summit in December to demonstrate the integration and workflow we go through when planning implants, so their TA's could have a better understanding of the process when helping out the dental offices they support. I have noticed lately that several people have asked for a reference about the process, so I thought I would share it here in the hope it answers some basic questions for our community.
So, what do we need? Well, a BlueCam or OmniCam, the Galileos, XG3D, or SL 3D, the Galaxis software, and an SSI export license. If you are planning to mill your own guides, you need to ensure that you have the most current versions of the software.
We begin with the CEREC...we will designate the edentulous area as a crown(the material is irrelevant):
We will then want to take a nice scan to the contralateral canine(note that we do not need an opposing or a bite):
We will then design an ideal crown-contact strength is not important, and obviously we have no opposing so we aren't concerned with occlusion. Simply design the crown where you would like it and ensure it is appropriate in the arch form:
We will then advance to the mill screen, where we will export the file onto a usb drive:
These are my USB drives of choice:
The key to this is that we are exporting the SSI file, NOT the RST-this is only possible if you have the SSI license:
Next we, will open up our cone beam scan and start working through the software:
Once we have identified our nerves, we will click on the CAD/CAM tab and import the SSI file into the software:
We verify that we have the proper file and then go about the process of stitching it to our scan:
Now, it is time to plan our implant:
And here is our final plan, with the implant planned safely away from the nerve and centered under our desired final restorative outcome:
And at this point, we are ready to order(or mill) our guide:
This process allows us to place the implant easily and predictably, which also helps make the restorative phase very smooth:
Hopefully this helps some users out there as they are working through the integration process...time to gear up for the Super Bowl tomorrow!
Just wanted to give a quick heads up that I will be remaking the zirconia infiltration and anterior contouring videos in the next month or two to reflect changes I've made in the way I do things.
Here is a quick tip to get great finish...Diashine Course Soft. I learned this from one of my biggest ceramic mentors Bill Marais (this case below is his)...I know many of you are already using the Fine Soft for a big shine (and I use that too on Zirconia).
The Course Soft after contouring and before staining removes all the surface tension from the restoration. Since it's oil based it can be cleaned really easily with Steam. After Staining and glazing, it really creates a nice, natural finish. Check it out.
Watch Dr. Mike Skramstad as he discusses the key features and important tips for optimizing outcomes with Celtra Duo, a fully crystallized, tooth shaded block with dual processing pathways.
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