Blog Recent Articles
Access fill, whether screw or endo, always seems to be a topic of restorative discussion. What can we do to prevent the dark shadowing or grey appearance? We spend all of that time on the crown or implant solution then compromise the final esthetics with a poorly masking access fill. This case shows a screw retained implant crown. Teflon tape is first packed into access opening directly over the abutment screw(about 1/4 to 1/2 inch long). Unlike a cotton pellet, teflon tape can be well packed into the access opening to prevent the screw from backing out. Tetric EvoFlow Bulk Fill Shade A (Ivoclar Vivadent) is layered directly over the teflon tape, followed by Tetric EvoCeram (A2). The block is an emax MT (A2).
Dan Butterman did a great job this week presenting a webinar on restoring implants with the Atlantis system. I've done several cases to date working with DSG Clearwater Dental Lab. These cases can also be done with Atlantis directly now that Connect 4.5 has been released.
The workflow is very simple. Remove the healing cap and insert the Atlantis IOS scan body. These are implant system specific like our Sirona scan posts. Take the scan in Connect and digitally ship the file to DSG in this case or Atlantis directly through their portal. Now we just lt the lab do all the work. A very CEREC friendly abutment with excellent emergence is milled after verifying the design the lab sends for review. I've been using titanium exclusively, but there are gold coated and zirconia abutments available. The fit of the crowns to the abutment is outstanding. When the patient returns the abutment is simply torqued in and seating is verified by radiograph. The crown is cemented via traditional methods.
For the past many years I have been stubbornly fabricating all of my own abutments as I just refused to work with a lab. With the ease of this this workflow I am happy to have another option. The price point is going to be in around $300-$350 for abutment and crown. Another option is to have the lab mill your abutment and then email the Core File of the abutment design. The Core File is uploaded into the chairside software and we are able to design and mill our own crowns before the abutment even arrives in the office. The abutment alone is going to be in the $150-$200 range. This is slightly more expensive than using a tibase system, but for the many users not taking advantage of this feature, the scan and send may be appealing.
We have just uploaded videos that give the complete workflow for implants utilizing Atlantis to create custom abutments. You can find them here:
Also, we have a webinar Monday night:
Monthly Webinar - New Digital Implant Workflow for Atlantis Abutments Through Sirona Connect
The next cerecdoctors.com Academy exclusive monthly webinar
is scheduled for:
Monday, October 16, 2017 from 5:00 p.m. to 6:00 p.m. (PDT)
With the release of Sirona Connect 4.5, CEREC® owners now have a direct digital pathway for Atlantis abutments. This webinar will feature Darin Lockaby, (Director of Sales for Digital Implant Solutions, Dentsply Sirona Implants) briefly providing an overview of Atlantis abutments, the process of getting started and the step-by-step clinical workflow. Dr. Dan Butterman will review his clinical experience with Atlantis, describe when and why he uses this workflow, specifically relative to TiBase restorations and show some excellent clinical cases. We’ll finish with a short Q&A and a list of resources to support doctors interested in moving forward with this new workflow.
Once again, when you need info concerning CEREC, cerecdoctors.com has you covered!! Enjoy!
Those of you that were at my lecture in Vegas at DSW 2017 saw me do some bigger cases digitally. I thought I would post a case that I just finished that shows this workflow
I have seen this patient for some time and she has always told me that she does not like her teeth. She is mostly unhappy with 3 things:
- The lines and discolorations in her teeth
- The shape of her teeth (specifically #7)
- Tooth #9 was more facial than tooth #8
- The open incisal embrasures between the canines and the laterals
- The minor collapse of the buccal corridor
- The unesthetic crowns on #3 and #14 (recession and margins that showed)
To give you an idea what she was seeing, here is her smile:
I knew that we didn't need to change a lot...She had a very normal tooth display at lip at rest for a 46 year old woman:
I think it's important to REALLY talk to the patient about what they want so you are clear when designing the case. She made several requests including the following:
- She wanted her concerns fixed, but didn't want people to know that she had fake teeth. This meant a very natural shape that almost mimicked what she had now... just chaning the shape and buccal corridor a little bit
- She didn't like the "blue" at the edges... which means I have to watch the incisal effects
- She wanted a natural shade... nothing bright. More natural
So I took this information and scanned her with the Ortho software. I exported the scan to my lab technicial Bill Marais and he digitally designed the smile via Exocad. Now often times I will have him send me the case via .stl and I will 3D print the case and use as Biocopy. In this case we did more of a "hybrid" approach in which he "milled" the digital waxup on a 5 axis mill with a grey "puck" and then used his hand skills to define certain areas. We did this because I wanted details and it's difficult to get this kind of detail via 3D printing.
Next we duplicated in white stone just in case... I use this to make a Copyplast matrix for a reduction guide, to transfer the waxup to the mouth for depth reductions, and also to fabricate provisionals.
We went ahead and prepped the teeth. We made the decision based on the waxup to prepare more of a full coverage veneer type prep. We tried to keep everything in enamel as best we could due to this prep style. We prepped a little more based on the decision to move the teeth slightly lingual in the anterior. This also helped us control the function:
Tissue control is very important. I don't like dealing with inflammed gingiva so one tip is to make sure you pack cord prior to defining the margins so you protect the gingiva:
IMO, it's very important to get the waxup model to stitch with the prepped teeth. This makes a MAJOR difference in how easy the design is and how much closer it will replicate what you are trying to execute. For this reason, we left the molars intact (no waxup on these teeth either) and use them as stitching abutments to correctly overlay the waxup to the preps:
By doing that, here are our designs.. initial proposals took very very minor tweaking (only about 5 minutes)
I went ahead and exported the .stl of the preps and 3D printed a prep model. It was a solid model so I manually ditched the margins with a bur to get the restorations to seat. Here are the e.max restorations milled in EF mill (Extra Fine for better trueness):
I did some small incisal effects with Ivoclar Ivocolor and then polished the restorations (no glaze). Here they are ready for delivery:
And here are the final restorations bonded into place with Variolink Esthetic warm. She was very happy with the result. I think I could have maybe done a little more contouring (some washed out in the picture)... but shape is always the most important thing and we did what she asked... creating more of a monolithic tooth with a natural shape and natural color:
I posted about this case a week ago. Her periodontist called #9 hopeless and was all set to extract it and do a bone graft. She wants to keep her tooth as long as possible. She was fully informed of all possible consequences and wanted to proceed with a crown. When the preparation was completed, two red spots appeared on the labial axial wall. There was no bleeding noted. Initially Theracal was placed over the spots but discretion seemed to be the best approach and Endodontic therapy was done to prevent the almost certain onset of post operative pain. This patient is not a happy person. The first time I have seen her smile was when she looked at her tooth in a mirror. We'll see how long this lasts. The extraction and bone graft can always be done when this fails. This is not a Bill Marais quality job, but it is a huge improvement over the pre operative situation. The software had similar issues with this tooth as it has when proposing an implant crown in an edentulous space. But she has a low lip line. This was Biocopy from a waxup. Not the best stain and glaze job. The assistant chose the wrong Programat CS setting and three bakes were necessary but the patient is thrilled.
Personality plus is the only way to describe Brian. This young Father appointed with the singular focus to improve his smile. Not for him, but for his wife and young kids. He was tired of being made fun of and was finally ready to tackle these unflattering lateral incisors.
He can’t even remember how long he’s had these restorations. I can’t imagine how long someone could look at themselves in the mirror each morning and think that this was a “look” was acceptable. Never the less, Brian was ready for a change.
The existing Maryland Wing bridges could not have originally be fabricated with the laterals so angulated and out of the alignment. I couldn’t imagine what could have caused these restorations to migrate into these positions over the years. Without understand the how and why, we pushed forward with a plan to reconstruct proper contours of the laterals with either new Maryland Wing bridges or Cantilever bridges.
Due to the asymmetry of the centrals and the mesio-distal spacing for each lateral incisor, we agreed to prepare the centrals for bridge abutments and cantilever the lateral on each side. This allowed us the greatest opportunity to control the esthetic outcome.
Both centrals were prepared for full coverage crowns. The case was designed using BioIndividual, Biojaw was used to create the final proposals. A 4 unit milled TelioCad bridge was fabricated has a provisional for the patient. The temporary was also used as a template for the final contours. Printed models from Infinident were ordered. These can be very helpful during the final shaping, texturing and the stain/glazing of the final eMax bridges.
After the patient approved the restorations, the bridges were bonded with Ivoclar’s Esthetic Cement protocol.
The patient was very pleased with the final results, giving him a new found confidence and smile he could be proud of. His children will now need to find something new about Dad to make fun of!!
Just thought I would share a case I completed on Friday where I previously succumbed to the definition of insanity-doing the same thing over and over and expecting a different result! Patient is a 46 year old male(neighbor of mine) who has a clear history of bruxism and has had his lateral incisors bonded many times(including by me) over the years. Here is how he presented:
Now, the last couple of times I really tried to make sure there was no pressure on the laterals...we have had discussions about a more comprehensive treatment plan but that is not really in the cards for him at this time. He was looking for a more definitive solution for the laterals, and I was trying to figure out why he keeps snapping his bonding off. Well, trying to think about things a little more thoroughly, I took a look at his maxillary canines and his lateral movements-here is what I saw:
Obviously, he has lost his canine guidance and has been whacking on the laterals, which has caused him to ruin any bonding he had done. I probably could have bonded this 100 more times and still had the same problems. So, we decided to try something I picked up at a composite course from Dr. Ron Jackson(great instructor, by the way), and restore the canine guidance with composite-now, this will likely wear back down over time, but we can monitor it at his recare appointments and "refresh" the composite as needed-and since an overhaul isn't a possibility right now, this is a nice compromise. So, we prepared 7 and 10 for all porcelain crowns, keeping the lingual margin above the cingulum to preserve as much tooth structure as possible, and built up the incisal edges of 6 and 11 with composite:
We restored 7 and 10 with e.max A-3 MT with some white at the mesial line angle(Kris:)) and a little sunset at the gingival...added some texture to try and get the appropriate light reflection. The patient was happy(as was I), and hopefully this gives him some stability in that area. I have had many frustrating cases over the years where I have bonded an anterior tooth only to have it get chipped a few months later...especially when I have stayed in the "single-tooth" mindset. Probably could have saved myself a lot of headaches just by thinking about things differently, as in this case...hopefully this helps someone else who has faced the same situation!
Got a new patient and he said he was ready for his implant crown. The implant was placed a out a year ago. it is so challenging to restore poorly placed implants and tales so much more time to get compromised results when there is poor planning.
the implant was too distal and too palatal. That made it more work then this should be. Just a tough case and the position compromised the final result.
Here is the second case presented at DS World. Another case where things didn't go quite as planned but it had some good tricks and tips.
This is a woman who is in her mid thirties, an engineer and has a twin sister. She had trauma to #9 and her smile no longer looks the same as her sister's smile and she wants it fixed. She also hates the grey band on #8. She has had several consults with different providers and would like both of her front teeth fixed. The important characteristics to her was that they were the same size and they looked "natural."
I struggled a little with this case prepping #8 because there was no prior work done and this was purely for esthetics. I brought up different possibilities of what we could do, but in the end the patient really wanted to teeth to match. For esthetic reasons, it is best have similar prep designs. I also chose to use an opaquer to block out the grey band in the tooth.
For this case I decided to use Biogeneric Individual. This is a case I did in one visit so I did not do a wax-up. When I design case like this, I love to use the Grid Mode to line up the midline and angles of the teeth. This can be placed easily by pushing "Control G".
The other tool I like to use to measure the widths of teeth when working on multiple anteriors is the distance tool. This can be found under Analyzing Tools. In this case both widths were 8.6.
When I first planned this case I decided ot use Vita Mark II because it is gorgeous and can mask a lot of color. After it was milled, I tried it in and it was a little bright but I was going try to tone it down with some staining and glazing. Right as I went to hand the veneer to my assistant...
Yep, I dropped it and when I took a breath in and moved slightly it was like it jumped right under the wheel of my chair and I heard that distinct sound of breaking glass. What a day! The other fun fact was I had no other Vita blocks so I needed to remill. I tend to think Vita Mark II is similar to e.max MT blocks so I chose to remill in an e.max B1 MT but unfortunately this was just way too bright. I use MT a lot in anteriors so I am not one to say they are always too bright. I think they are often really beautiful but if you really look at her original smile she has a lot of translucency and grey in her teeth- more like a c value. I should have picked this up but I didn't, so I milled this case for a third time in one day and settled on a B1 HT.
What can really make or break a case when working on front teeth is making sure you have similar facial contours. I check this by looking down the incisal edges and also by taking pictures to make sure my reflections are similar. I also decided to keep the cingulum on #8 for added strength.
This case didn't need a ton of staining- just some white to set the framework and some I2 for translucency. When I am staining anteriors I always follow a pattern and my assistants do the same.
1. I paint on the glaze first all over the tooth. This is thick in consistency but thin in thickness. I do not mix the liquid in this.
2. I do my body stain next and blend it in the gingival third, however in this particular case I did not feel she needed it.
3. I paint translucency at the incisal edge in a zigzag pattern with a light touch about 1mm down or so or following the pattern of neighboring teeth. In this case I painted the I2 about a 1/3 of the way down.
4. I frame the tooth with white or cream. In this case I used white and just at the incisal edge and mesial and distal marginal ridges
It was a long day but she got caught up on her Netflix episodes and was happy to wait for a result she wanted. She understood that I had other cases at the same time and was grateful we were willing to remill to make it right. She was happy when she left.
I had the incredible opportunity to speak at DS World this year and was asked to post the cases I presented. All three of the cases I will post were done on a random day in my office. The same random day. It was a day that didn't go nearly as planned but at the end of the day my patients were happy and my team was profitable. It was a win-win. Here are some tips and tricks I've learned over the years from others willing to share their cases before me...
What's the first thing I think when I see a case like this? This patient needs comprehensive care. He needs ortho in an ideal world but declines the option. The dark tooth on #9 had never bothered him until now due to a wedding in the near future. Tooth #9 has had previous endo. When I see a bite like this my first instinct is to use BioCopy because I don't want to mess with nature. I also lean towards e.max. It is strong and forgiving and easy to stain and glaze.
The burs I actually use isn't really that important but here are a few tips on preps. For efficiency sake, use a pattern and stick to it. The best advice I got was doing axial walls first, then reduction, and then smoothing off any sharp corners. I try to use no more than three or four burs and always in a specific order. I see so many doctors get caught up in the small details and determined to use as many burs as possible going back and forth between them. This is not efficient. Have a system. Don't bounce around.
I also use a lot of opaquers when I work on anteriors. This allows me to use more translucent blocks by blocking out the color underneath. My personal choice is Cosmedent's opaquers. In this case I chose A2 so that the substructure would match that of #8. These opaquers have a consistency like flowable composite and that is how to treat it. Etch, bond, add the opaquer and then image.
This is a perfect case for the articulator function. I will be honest, I wasn't using this much in the past until I went down to Scottsdale to mentor and I think Sam was telling me how much it has improved and can really help out with post op sensitivity. I decided to see if this was true so we started tracking it in my office. We decreased our post op visits by 43%. Crazy! Of course there could be other factors but we don't believe we changed anything else other than starting to use the articulator function to remove interferences.
It's pretty obvious that #9 would cause an interference. It's longer than #8 after all... but this was my first mistake in this case. I assumed that of course he would want his teeth even! You know what they say about assuming...
My other quick design tip is to close the gingival diastema (or the dreaded black triangle that looks like pepper) from the lingual using the Shape > 2D Circular tool.
Here is the immediate seat. It looks a little low in value which is normal when the tissue hasn't healed all the way. My assistant did a great job staining the tooth trying to mimic the coloring on his other teeth. He was happy and left the practice only to come back about an hour later. The problem wasn't that he didn't like the shade, it was that he couldn't "bite the skin of his lips". He was pretty distraught about this. I gave every explanation of why his teeth should be even and that he would get used to this, but to no avail. He wasn't leaving until this was fixed. Out came the consent form because I wanted to be clear...
So I cut off the freshly bonded crown and remade it. My assistant was helping out with another patient so I got to play with the staining on this one... I also was able to use the same block to mill out the second crown so that was a bonus.
I really love using white as a distraction. Matter of fact in James Klim's lecture he calls this the "Art of Distraction." It just means that you get to be a little creative in your staining. Don't use super straight lines with your stain. That is what makes it look fake. Have fun with it. Light touch, feather like in design. I used e.max stains for this e.max A2 MT crown. More tips on staining and glazing in following cases... Stay tuned!