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Wanted to share this case that I have almost finished up. Little back story is patient came in with quite a bit of pain. Two fistulas on 4 and 14 I believe and a large pulp cap/IRM thing done at a clinic somewhere on number 11. Other than that lots of cavities on most of her upper teeth. She was ready to pull them and go to dentures because she didnt feel like she had the money.
Well thankfully she walked into our office! Not because I am some dental wizard but because I am a GP who does a good bit of procedures and I love cerec. So I basically said hey, I want to help, why don't you let me just fix whatever I have to fix for a flat fee! We agreed on a price and off we went. We ended up doing 3 root canals and 13 units on top. 1 implant, 1 root canal, and 2 crowns on the bottom(We still have to restore the implant in a couple months). My cost for everything in materials is under 1,000 bucks easy. I ended up doing everything for like 10k so I still made a great profit, got tons of experience, and now have a referring patient for life! Anyways wanted to share because I love that cerec gives me more flexibility to work with patients on cost for these large cases becasue my lab bill is so much smaller. I probably would have spent 4K easy in lab without a cerec!
Wish I had done this case after level 4 a couple weeks ago hahaha, my anterior crowns would be wayyy better! But as you can imagine she is thrilled! And if you arent doing it you should seriously start asking patients if they dont mind sharing there story/experience...she was like of course, I want others to do this!
CEREC- The Universal Language
I have just returned from a wonderful life experience. One that showed the world is small but also that CEREC can be a universal language that spreads around the globe. Not only the group assembled was wide and vast from across north America, but the interactions with those beyond our boundaries demonstrated a common goal. CEREC also has crossed over generational divisions, we saw the past and we have been teased with the future.
We embarked on seeing what is coming in the world of Dentistry from around the world at IDS, from the many manufacturers present. This was followed by field trips to some of the companies we have current ties to.
We had the chance to have a private visit on a Saturday, Tobias Lehner came in and opened the doors to SICAT and our eyes for software refinements they are working on. At SICAT we saw their commitment to making our lives better through refinement of the software used for our imaging, 2 D radiography and our 3D radiography. They have listened to our concerns for improving how we plan and treat our Implant cases, our larger restorative cases where the articulator function will mesh with the CEREC system. Bringing us closer to the true virtual patient. Also exploring other areas where we can benefit, in particular endodontic therapy. Helping us to unlock the anatomy of the root canal systems present in the teeth we treat. Combing 2D imaging with our 3D imaging and working with the anatomy of the specific tooth. Allowing us to fully evaluate, treatment plan and perform endodontic therapy better and more efficiently.
Ivoclar opened the doors to their headquarters to allow us to see some of the magic that happens there. They showed how they develop products that are used on our patients through their whole dental life, from when teeth erupt to when teeth are lost. They create solutions not only for the largest part of our practices, restoring teeth by fabricating partial coverage and full coverage restorations, bringing our patients back to function. Ivoclar helps in the more complicated process of replacing the missing tooth, fabricating bridges and restoring the implants that solve these problems for our patients. And now digitally constructed full dentures, offering simplicity and efficiency to a laborious process.
The future for the digital workflow is expanding. but there was a day that was priceless where we had the opportunity to get a history lesson from none other than the originator. Prof. Dr Werner Mormann, a man with the simple wish to improve the way we could restore the damaged teeth our patients present with, and the determination to devote his life to make it a reality. A single visit ceramic restoration done in an economical way.
It was an honest and insightful visit where you can see his passion for improving the system continues. Improvement from a dentist for a dentist designed system. In fact when discussing the Redcam Dr. Rich Rosenblatt said “Dr Mormann even the original camera is smaller then many of the current intra-oral scanners available” and with that Dr Mormann responded “not only smaller but faster and better!” with a large grin on his face. Followed by “and we are always looking to improve the imaging”. A pioneer who realizes he needs to evolve and grow his ideas, to continue to push the technology to the limit. This look at the past was followed by a look at the future with Dr. Moritz Zimmerman with the upcoming 4.5 software. It was a talk that teased us with improvements but also clarified questions of the past.
Materials, techniques, software and hardware all combining to create a focal point for the special group in the world of dentistry. We spoke with people from all around the globe, sharing thoughts and ideas. We made friends due to a common desire, a common language.
And that is what CEREC is, and with the hard work of many, it will continue to be.
I have been asked about this a lot, so I thought I would post a quick case...
In 4.5, you now have the ability to dry mill zirconia abutments with carbides (can wet mill with carbides too if you do not have the new mill). The advantages of this are going to be smaller sprue and time savings
Here is a case that I inherited. He came in with an implant placed on #8, and a crown prep on #9. He was wearing a cantilever temp as a provisional. He had a trauma at work and both #7 and 9 had RCT as well. Implant was a 3.3.Straumann Bone Level
My plan originally was to crown #7, Implant custom abutment and crown on #8, crown on #9 and do a composite on #10 to make more symmetric. He declined the composite on #10 or now because he didn't think it was necessary and was not too conscious of the esthetics.
I was mostly concerned with the symmetry of the centrals, so here is my original plans:
Here is what the design of the centrals and the dry milled custom abutment looks like:
and here is the final result:
I thought I would start an official thread for you all to ask questions and to archive the conversation on some of the new IDS announcements today and the V4.5 software.
We will be making an entire new catalog (all videos for every indication) with V4.5. Expect to see these videos later as the software gets finalized. However, we will release some additional preview videos after we all get back from Germany.
- Release of the software will likely be sometime in June
- No cost is currently available for the new HUB (see below) or color calibration unit (I will be inexpensive)
So here is an outline of some of the news from today:
CEREC SW V4.5 will allow you to export .stl file in the model phase. This will allow you to do what you want with the case or 3D print it in your office if you wish. You will not be able to export restoration data as .stl files.
CEREC Software V4.5:
- Faster Imaging
- Photo-realistic proposals
- Better color in Model
- Edges of preparations are displayed better
- Precalculation of data during acquisition (models still spin, but will speed up process)
- Auto recognizes restoration type
- SINGLE model phase
- Auto insertion axis
- Continued Better proposals
- Better milling and grinding strategies for better fit
I posted a video on another thread and will repost it here. The Omnicam will recognize shade. It works really well and the software will tell you based on your scan the best areas to take the shade!
Zirconia Abutment Blocks:
New precolored CEREC Zirconia blocks for both Screw Retained and Cement Retained solutions. They also will be able to be dry milled with the carbides.
Hub by Dentsply Sirona:
This is a cloud based data backup and archiving unit.
The hardware will be a networked data center for backup and transfer of CEREC cases. It will be available even when the AC unit is turned off
It will have it's own security and allow complete syncronization of CEREC data between all workstations and AC units
That is all for now. More later.
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!