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Webinar synopsis: This webinar will show in detail how important the Digital Workflow is for blending the Orthodontic, Surgical and Restorative treatment plans. The webinar will also show the importance the digital workflow in an orthodontic case when the patient is unable to come to you office on a regular basis.
Dr. Jeffrey Briney is a graduate of Indiana University and practices in Dana Point & Laguna Beach. He speaks around the world with regard to his personal approach to Surgical, Laser & Restorative Dentistry complimented with Facial Esthetics & Orthodontics. Dr. Briney can be reached at firstname.lastname@example.org or through his website www.drbriney.com.
I’ve been a Cerec user for over 9 years and I am continually amazed at what this technology allows us to do for our patients. I saw this 20 year old patient last week for a consult to have her veneers on 8,9 redone. She had a large composite on 8 from trauma. The previous Dr made 3 attempts (with the patient in temps for 3 weeks in between each try in) to please her and the final attempt she had to drive across town for a custom shade and still wasn’t happy with them. A few weeks later she had some porcelain chip at the facial margin and the Dr refused to see her according to the patient. Her story raised some red flags to me and I was a little nervous I would be able to please her. After examining her existing veneers, they did appear too long and bulky and the surface texture, shade also didn’t match her existing teeth. She was blown away that I could remake them in one 2 hr visit. I used emax BL3 and the cerecdoctors meisinger polishing kit to add texture and polish prior to stain and glaze. She loved the results and her mom has an appointment this Monday as well. I love what Cerec single visit Dentistry gives us the power to do.
This was a patient who arrived at my office after a less than optimum orthodontic finish and failed hard and soft tissue grafts for the area of #8. I encouraged her to see my periodontist that I work with, but she was "tired and done". She couldn't stand her essix and wanted a bridge. I talked her out of it and said that we could do something as a long term temporary and then when she was ready, we could explore grafting and implants in the future. I bonded #7 to correct the mesial concavity. #9 was used as the retainer. I did prep slightly on the lingual of #9, but still kept the prep in enamel to maximize the bond for the restoration.
This was a 2 hour case. I stained and glazed in the mouth but still needed to do a second fire to get it to my satisfaction. I used IPS e.max A1 LT.
I saw the other thread about dual maryland bridges and this case was in my office today. forgive the pics immediate post op as I will not have time to take photos till later this summer when she returns from a school trip to Ireland. This pt has been a pt of mine since I bought my practice 11 years ago. she had 7 and 10 congenitally missing. we had her in maryland bridges made with lava ultimate since she was a soph in HS. she wore those for over 5 years and they held up well. I'll have to dig up pics of it. We used an HT block and it was a mistake. looked grey. she was happy to just have something while she waited for us to say she could get implants to replace the missing teeth. Very difficult access due to the lack of space between the roots of 6/8 and 9/11. she went back to ortho and they put her in invisalign last year to get more room to place some thin implants. We removed the Maryland bridges and she wore her aligners while back at school. Mom tells me that her daughter is going away to Ireland for a few weeks this summer and really wants this implants in to heal over the summer so she can have these restored sooner rather than later. Her daughter was coming home on may 7th and leaving on the 25th so this did not leave a lot of time. We needed to take a new 3D scan, cerec scan, plan the implants, make the maryland bridges, have the implants placed and seat the maryland bridges in less than 3 weeks.
She came in and I removed all the buttons from invisalign and scanned her upper, lower and BB. I took a new scan. I do not have a printer and my MCXL is one of the originals so I can't mill guides. This is where the beauty of this community comes into play. Dave Honey works in the next town. He lives close to me too. I contacted him and he was able to mill a guide and get me keys to give to my periodontist this past monday. The surgery went great. He put in healing abutments, stitched her up and told her to wait a few days and come to me to get the restorations bonded in. Dave, you are the best and thanks so much for your assistance to make this happen in the time frame we were stuck with.
She just left the office. I had to adjust the underside of the maryland bridge to allow them to seat over the healing cap. These were lava ultimate shade A1LT with wings on the canines. The stitches are still in. she is having them removed next week right before she leaves. I don't like the position of 7 when I look at the photo because it does not come in mesially enough for my liking. that being said, she is very happy to have the permanent solution. My perio wants her to wait till xmas to restore these. He is fantastic so I'm not messing with him. She has an invisalign retainer she was wearing with the fake teeth in 7 and 10. we'll take off the maryland bridges when she is home for xmas break and then have her wear the retainers while we make the final crowns. I'll take photos of what she looks like when she returns so we can see tissue response and such and then I'll post the final case next year when we seat. This technology made a much easier surgery for my periodontist. It allowed me to get him a guide in a very small time frame. It allowed me to make fixed temporary restorations and I was able to rely on a friend and fellow cdoc community member to help me out in a time of need. I love the place and I love this technology.
Here is a tough implant case that walked through my door a few days ago for impressions. He was referred to me by the oral surgeon, post placement.
This is a young man who has never had a filling, but had got into an unfortunate accident with the handlebars of his bike and the bike obviously won. He went through root canal therapy on #9 and #10, crowns, retreatments, extractions and finally implants. He was ready to be done and have teeth and the surgeon told him I could do it in a day .
So this is what I see...
1. two implants next to each other in the anterior that are not easy to restore
2. Not awesome tissue or chance for a great papillae between #9 and #10
3. Distal inclination of #8 and an overlap of #7/8
I have the discussion with the patient:
Do you want ortho to straighten up your central?- "no"
Do you want to add composite on that tooth to make it appear straight?- "not really "
Did you have a gap between your front teeth before or a space?- "no, I want them to touch"
Would you be interested in another gum graft if possible?- "I really just want teeth that don't come out at night"
So here is what I came up with. I could not split this case because there was not enough room unless I put the margins on the abutments up pretty far above the gingival level. These are screw retained.
I was pretty excited about the staining and glazing. I used an A1 LT and carried the shade 1 down towards the incisal to match his other teeth. Here is what I am struggling with:
I don't love the midline slanting and wish I would have just placed composite there instead. The reflection on #9 tells me that I need to flatten that part of the facial wall just slightly and polish it back up to mirror the other central. Last but not least, I don't love the embrasure space between #9 and #10 but I am not sure if that is possible to fix.
Would a graft work here? Pink porcelain might have been an option for an illusion but super tricky, especially without a model. The other option I am thinking of is Anaxdent Anaxgum paste. I have never used it but saw it on another post... Has anyone tried it?
I am hoping to accomplish this:
but how possible is that?
At the end of the day he was happy to have teeth. I am just curious on what other people would have done in this case. I don't think temporaries would have done too much because there isn't a lot of tissue to move around. The implants are shallow. I'm leaning towards trying the anaxgum because I wouldn't have to remove or refire the implant crowns but I would love other ideas too.
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I much prefer to post cases that are a slam dunk and turn out looking beautiful like this pre-op and 4 year post op case....
But unfortunately, some cases don't go this way. I hesitated to post this failure, but I tend to learn more from the cases that don't work out. This patient has broken almost every restoration that anyone has placed. She fractured the endodontically treated tooth #14 and I extracted it. I think I only waited 3 months to place the implant.... maybe too soon for this patient. I also went with a shorter implant to avoid sinus grafting.... mistake? Maybe with this case. I let her heal for another 3 months and placed a screw retained e.max/TiBase restoration.
Over the course of about 9 months, things went from bad to worse. I took the crown off, put her in a healing abutment, and grafted, but nothing worked.
So now what? The patient is asking for a bridge, and I'm honestly afraid that she'll fracture the retainer teeth in a few years. Like a lot of you, I offer to re-do everything for free. Right or wrong, she agreed to a new implant, so I changed everything about how I did the last one.
I did a sinus lift, with a bigger, longer implant and re-grafted.
I went with an Atlantis abutment ( I do think a TiBase would have been fine on this case), and I put the softest material I could think of on top, Enamic.
Although I kept the occlusion light, the patient still was functioning heavily on the crown. When she bites hard, I think her natural teeth move apically a lot more than normal.. this is the wear on her Enamic crown after less than a year (delivery and about 11 months).
She appears to be doing well now as far as bone levels around the implant, but time will tell. In the end, I waited longer, grafted more, used a bigger implant, better contour abutment, and softer crown to try and take up some force. Maybe none of this mattered and the case failed for other reasons, but hopefully this is the end of a very long story :)
Now that I've got your attention, let me give you some context: I had a resident come through to observe a few months ago, and on seeing the clinical presentation of the proposed site, she felt that there was no need for a guide or even CBCT, and that she could close her eyes and treat this patient.
Having followed what is now standard protocol in my practice, I took advantage of the integration of CEREC and the SL, merging the files and creating a prosthetically driven treatment plan. You will note the potential for problems in this surgery due to the very large incisive canal in close proximity to the planned fixture position, hence the surgical guide.
I printed my surgical guide with the Formlabs printer and performed my osteotomy; I have come to expect these guides to be very consistently accurate.
I planned on enucleating the nerve and grafting at time of implant placement, as it was clear from planning that there was inadequate bone on the palatal side for this fixture.
I saw him for his 4 month follow up last week and his healing looks acceptable enough that I am releasing him to his restoring dentist.
I was thinking about this case and the comments of the resident, and I imagined attempting the case without the benefit of three dimensional prosthetically driven planning. I was thinking about how hard it would be to keep my osteotomy true without the benefit of the guide; it would be so easy to end up either too far buccal, or perhaps perforate the palatal and end up in the incisive canal space. I went back and looked at this view again...:
...and it reminded me of why I made the commitment to add this technology to my practice: it increases the quality and consistency of care I can provide for my patients. In hindsight, working without these tools and their protocols is very much like doing it blindfolded, and it is not fun.
I am by no means an expert in 3d printing but I have enjoyed getting acquainted with the process - thanks for all that post on here and those that I have contacted that helped me to start to utilize this work flow. Here is a case that highlights the blending of CEREC implant planning and 3d printing with the Astra EV line-up.
Initial presentation - history of trauma as a child and this long time patient called with significant discomfort and a mobile tooth - he wanted the most predictable long term solution which I felt was a dental implant. Patient is a medical doctor and did not want a flipper so I milled a splinted temp with teliocad for use as an interim.
Tooth was extracted in June and I waited 5 months for healing
CEREC and Gali images merged and plan completed
I sent this case out to Sicat for guide design and then downloaded and printed the guide. The metal sleeves I got from Sicat directly.
Guide was printed on moonray printed in office - I also printed a model just to verify the fit
Time for surgery, removed splinted provisional
Surgery completed Astra Tech 3.6 X 9mm implant and I did place healing collar, modified provisional to relieve all pressure from surgical site and placed provisional back on. I do use Durelon on these long term provisionals as I have had better success than using temp-bond
I will post final restorative pictures once that phase is complete - suggestions and ideas to do this better are always appreciated!!
I have intra oral cameras in my 4 ops. 2 of them have digidoc cameras and at midwinter I splurged on a trans illuminator for one to see if it would help me show patients what a crack can look like or to see decay that may not be easy to see with BW. This was a case from today that the pt will be doing 2 crowns after seeing the photos. I tell people all the time to take lots of photos to explain to patients what is going on in their mouth. It allows them to see it and take responsibility for it. This is from today. I love investing in technology that helps us communicate with our patients. they say a picture is worth 1000 words, but it this case it was the pt realizing she needed 2 crowns to protect those cracked teeth.