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There was a thread last week when Sam kept asking why not Feldspathic Porcelain for a Veneer or an anterior crown. For me personally, a lot of my decisions for block was a matter of very my comfort was, and not being familiar with the properties of other blocks. After going to Level 4 a few years ago, it was the first time I really saw Sam and Mike's affinity for VITA blocks. As we can all attest to, Mike's case make us want to cry sometimes because they are so good and makes me wonder what type of "hack shop" I run :)
Everyday I get better and better with understanding block selection for certain cases, but as I use VITA Mark II or VITA Triluxe more, I really like the esthetic properities of the materials and obviously being able to see color straight out of the mill is a huge benefit too.
Here are a few cases that I have done to showcase the power of the block. Obviously, VITA isn't the strongest material we have so if strength is a major concern for a cause, I would revert back to blocks like Celtra Duo or eMax.
This patient hated the spaces at the gingival 1/3rd of her lower anteriors. She is post ortho and I inherited the case after the ortho was already finished. We discussed the challenges of closing the spaces completely, and I wanted to prep them as conservative as possible but essentially they are crown preps because I had to prep interproximally to the lingual aspect so far to help with the space closure gingivally, and was only able to preserve the lingual cingulum of the lower teeth. Funny how pics show all your flaws, but I swear I rounded all the preps with a 3M finishing disc and they still look to sharp in a lot of areas. Fortunately, the restorations all milled and seated beautifully. This was a case I did same day. I have 1 mill unit and used Biojaw to help with the design of the crowns, and the patient was in the chair for about 4 hours.
Day of Pics:
1 month Post op:
Ironically I didn't stain and glaze the case. I tried the crowns in and polished them slightly but when I tried them in, she was so happy that she didn't want me to do a thing. So I polished them completely and bonded them using a total etch technique with Variolink Esthetic Neutral. The blocks were VITA Triluxe 1M2. I still am pretty amazed that we have materials that can come out of the mill, be polished and bonded and look like this.
Patient needed veneers on #8 and 9. Again I used VITA Triluxe (A1C) and bonded used total etch technique with Variolink Esthetic Neutral. This was one of my first cases with using GC Lustre Paste. I hate the texture. Part of the learning curve of using Lustre Paste. It really is apparent in the photos but the patient loved them so much that she didn't want me to touch them. One of these days I will find an excuse to polish this veneers more :)
Day of pic:
1 week post op: Sorry about the articulating paper mark...ugh
This was a really frustrating case. Patient hated her crown because of the dark grey margins and asked if I could improve it. I tried and failed with emax LT. Ended up sending her home and milled out a few different blocks and the one that looked the best was VITA Mark II A1. I did bond this with a Variolink Esthetic Light. This was stained and glazed with Lustre Paste. The whole reason I chose to even mill the crown in Mark II was because I was reading about a veneer case that Mike had done where he was able to conservatively prep for a veneer and block out a reasonably dark prep. So I thought, what the heck, I'll try it. Not perfect but the patient was pretty happy.
Color of core after PFM removed:
Thanks for the update. Not too lengthy. Very much appreciated.
Here is a fun case I did today:
Patient came in with fractured lateral incisor (#7). Was a virgin tooth that he fractured on a peanut... It had exposed his pulp chamber and was painful
We went ahead and did endo on the tooth first:
He has a lot of lingual tooth structure left (plenty for ferrule and lingual is most important for tension forces):
We sandblasted the prep and bonded on his fractured tooth with total etch, Scotchbond Universal, and Rely X Ultimate (etched and applied Scotchbond to tooth as well):
We did a Biocopy and then prepped a full coverage crown on the tooth:
The final restoration was 3M2 Vita Trilux stained and glazed to match his existing teeth. I also show the contrasted picture so you can see the nice effect of the Trilux Block...
Did this case today, Extracted #8, immediate implant placement with grafting and custom healing abutment. I really am enjoying this work flow. The final crown is ready to mill from my Omnicam Image today.
It takes about 18 min to mill Enamic and another 10 or so to cement it to Tibase. In this case I was doing implants and grafting on the lower left as this was done.
Just a fun little case that I finished today. Nothing special, just bread and butter.
Gold Crowns on #3 and 4. #3 had decay underneath and #4 had vertical root fracture.
Extracted #4, let heal 6 months, Implant placement, integrated 3 months, inCoris Abutment (F2) and e.max LT crown. I could have done e.max screw retained... but I did not have the right shade in stock :)
Zirconia Crown #3... polished.
Will give you and idea of what CEREC Zirconia (polished and no infiltration) looks like next to e.max. Not terrible... but why I try and infiltrate lately to lower value more... very opaque
It must be a full moon, because I've recently had three or four cases of young patients falling and causing a fair amount of dental trauma. This beautiful young woman was very happy that we could get her smile back!
There are many threads always going on asking "what block should I use". I will tell you first off, this is almost impossible to answer just by looking at a picture. Ross Enfinger has a really nice thread on this as well.
Just one quick case that will basically give you my theory on anterior teeth cosmetics.
- Always use the most translucent block that will get the job done
- All the natural value, translucency, and opalescence is in the enamel... so if you remove all the enamel, your job is going to be more difficult making the teeth look natural.
- Always as conservative as possible. That is, Veneers always before Crowns if that is appropriate. Veneers are hard, but crowns are much more destructive to the tooth. The more you prep the tooth, the biomechanics change quite a bit and it weakens it dramatically.
- Don't forget composite. After sitting through part of the Spear Composite course last week, I was reminded that we should use composite more in the anterior than most of us do.
Here is a case:
Woman in her 50's came to my office for a consultation on her anterior teeth. She had a pretty nice fracture in #9 and #8 was chipped on the incisal edge. Both teeth had a fair amount of erosion on the facial as well.
We talked about 2 options really: Composite and Veneers. She really had done some research on this already and visited a couple dentist with varying opinions (some to crown the front 6 even) and knew she wanted veneers. I was personally relieved because I didn't want her to choose composite because then I was going to have to execute it :)
After we decided on veneers on 8 and 9 I had to get an idea of what material to use. She has a lot of translucency, so my choice was either e.max HT OR Vita/Vita Trilux... I wasn't sure quite yet. I was concerned about the wear on the teeth, but I also knew that Vita was going to be easier. Either way, I knew if I was going to control translucency and value, I needed to control prep. With her facial erosion, it would be easy to over reduce and increase the material thickness (thus decreasing the value).
So the next thing we do is a quick composite mockup:
From here we can do our proper depth reductions using the Winter Reduction Burs from the Restorative Design Kit and get conservative Veneer preparations:
In the end, I chose Vita Feldspathic veneers on her and protected them with a night guard. You also could have used e.max HT I feel and got a great result as well.
Hopefully this helps and spurs some additional thinking. Also read Ross's thread. I will try and link to it.
I've been using the Verban drill stops with the CG2 for some time and have enjoyed lots of success with it. I recently started using the new version of the drill stop made for the Densah burs and like it a lot better.
The original drill stop fits up against the hub of the handpiece, so the vertical depth is controlled when the handpiece bottoms out on the guide.
The new version of the drill stop sits passively on the Versah drill and can slip up and down until the stop makes contact with a silicone ring that you place on the drill at your desired D2 depth. It also has a lip that engages the guide. This allows more flexibility in setting the D2 value and makes for an easier vertical stop depending on the geometry of the guide.
The D2 is calculated by adding up the length of the implant, the distance from the implant platform to the gingival crest, and the length of the stop. I like to add 1mm on to that length to make sure the stop doesn't prematurely contact the gingiva before the final depth is reached.
In speaking with Dr. Verban, I believe there will be a modification with the silicone stops being made of metal and added to the stop, but the premise will remain the same. This stop allows the ostetomy to be performed for most implant types and situations using a minimum amount of costly instruments.