Underutilized use of CEREC: GC Cerasmart inlay
This case is one of my favorite things to do with the CEREC machines because it is a service that no one without a CEREC could ever imagine doing in such an efficient way. It is also extremely predictable, and cost-effective for the patient to boot. This is a patient that has floated in and out of the practice, never really getting comprehensive treatment done, but always with some sort of restorative need. Today was an extremely busy surgical day, so when I saw her show up on my schedule as an emergency appointment, I wasn't really sure what I could do to help her. Luckily we could work her in and deliver definitive treatment to the area today.
Patient presents with an existing occlusal alloy in tooth #19 with recurrent decay that undermined the distal marginal ridge. The tooth cracked around the alloy in such a way that direct replacement with resin would prove to be very time consuming, and clinically deficient. A full coverage restoration would be extremely aggressive treatment. I presented the patient with a treatment plan of replacement of the alloy with a milled hybrid composite inlay. 
I removed the alloy, prepped with draw, and imaged. No opposing model needed
While the model was processing, I removed the last bit of decay that would have caused an undercut, knowing it will fill in with bonding cement. I also prepped the buccal pit that was stained. Perfect initial proposal, got it in the mill and moved on with my day. 15 minutes later, the restoration was ready to bond, I sat down, bonded it, checked occlusion and left the room. Total time with the patient, 45 minutes.
I love doing these hybrid inlay restorations, as it shows the patient how we really are focused on the best treatment for them. I never looked at the tooth and said, hmmm should I try to save it and do a resin, or should I just prep for a crown? In my previous practice lifestyle, I would have immediately started considering prepping for a crown and never looked back. Now this patient has a minimally invasive restoration at a fraction of the cost. I love sharing these cases with docs during trainings; you can see the lightbulbs turn on in their brains. The CEREC system has done a number of things for me, but most importantly, it has reprogrammed my brain to look at restorative situations in a much different light.
Great treatment John! I really like Cerasmart for this as well, but what is the green rubber looking thing surrounding all of the teeth?
Very nice!! I really like the GC block. I have been pushing the limits a bit and doing quite a few full contour crowns in addition to being my go-to for crownlays. It is by far my favorite resin/ceramic block.
Hey John, looks nice, good work. How are you billing these out....inlay, composite or ?? If inlay, how do you set up your fees vs crns?
JJ
Love the rubber dam. Get rid of that crappy green one and buy the blue Isodam. Work much better. Also get a rubber dam stamp to get the holes in the right place. You want it in the papilla perfect and it will compress papilla and prevent any bleeds ever. Are the composite thread from yesterday.
Dan I know....what the heck is that thing?? Seriously though, it's SO good to prep and bond with! I wouldn't have ever believed it until we spent the entire week using a dam. The assistants go "oh the patients will hate it". Well guess what, they hate everything we do anyways. And I've asked for feedback, patients have been happier with the dam vs isolite overall....yikes. A youth was really excited about the rubber dam (still not sure why) and put it best: "They keepin it 100" except it sounded like "Dey keepn it wunhun ded". Made me feel like I was really cool when he said that.
Mike I knew you would love it. Just ordered Ivodam. Tell me only ordered them because of the stupid Vikings...
Very nice. Pretty prep. Do you seat these with warm composite or bond them in? I wanted to try one of these a couple of weeks ago.... It's been so long since I have prepped an inlay I obliterated a couple of cusps trying to keep draw and ended up doing full coverage. I need to work on getting a clean minimal prep quickly like this. I feel like I can do a crown that fast just because I'm well experienced at it.
I am new to this, like I haven't even received my new CEREC yet. My question is if down the road you wanted to put a full coverage crown on this tooth, would the inlay work as a core?
Aaron! Glad to see you on the board. Great question. A bonded hybrid restoration will function as a great core. Wonderful service to provide to your patient if finances limit treatment
I bill these as at my standard resin fee +$50. I'm not in network anywhere so I have a bit more leeway with this. In my other offices, we are ppo providers, so it's the contracted fee + and adjunctive fee of $50. The patient knows they pay for this out of pocket. Indiana has fought hard to block the trend of insurance companies forcing network providers to accept $0 for service codes they do not cover. so we have our own code that no one else uses and Bill it to insurance but they have no clue what it is and it's the patients responsibility
Love what you did for the patient. From a practical view, I still have a tough time dealing with the sprue and getting the things t seat n a reasonable time. What is your procedure?
I've found the sprues on cerasmart to be so thin that it's quite easy to differentiate sprue from restoration. I intentionally overdo the contact area in these cases just in case it gets nicked during sprue removal
On 3/4/2016 at 9:28 am, Matthew Hubis said... Care to throw out your favorite RD clamps for upper and lower molars?
Hopefully Mike chimes in. I'm just using what we have in the office, probably from the 80s
I'd love to do that. One of my goals for this year is to let go of some of my "control freakness". So you numb, leave, she images and places dam and you come back and start prep?
One of the best things you can do to make the rubber dam placement fast and predictable is to get a template.
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So Mike and those that use a dam for crown preps consistently...tell me your workflow with the dam? Pre image everything ahead of time, cut out preps and image preps only with dam on and leave it on until crown is ready? Or are you placing the dam twice? Once for prep and once for seat?
In honor of John's post about Cerasmart, I felt motivated to start using it more versus asking myself why I'm doing a direct composite on a tooth that really needs an indirect restoration...
This was a case on #2,3. Larger failing composites, but both facial cusps were intact and I felt full coverage was not warranted. So we did 2 onlays with Cerasmart. As many who use it know, it mills very nicely and polishes wonderfully and quite easily. Sorry Mike...no dental dam...still clinging to my Isolite at bit longer :) To bond it I selectively etch the enamel with 35% phosphoric acid, use Adhese Universal for 20 sec., and then used Variolink Esthetic Warm.
If you can't bill out an adjunctive fee plus your resin fee to minimize cost in a PPO case can you get 2 mills out of cerasmart like lava ultimate?
For insurance, if you are PPO, you can bill out D2999 and put in the explanation that it is a milled, indirect restoration which occurs added cost but is more durable and has a higher longevity. They still normally won't cover it but it's worth a try. Some insurance companies are better than others.
Nice preps indeed Dan. The Cerasmart does look gorgeous! I'll be curious to see how that ML cups holds up on #2 ;)
Mike- your alter ego Michael makes me laugh...you just happen to have videos stored on your phone when you are away or what?
We do paradigm mz100 like these all the time, particularly when direct composite would have a hard time creating a contact.
" To bond it I selectively etch the enamel with 35% phosphoric acid, use Adhese Universal for 20 sec., and then used Variolink Esthetic Warm."
What do you put on the cerasmart itself? Adhese on it as well?
So tooth: acid etch, adhese, cement
Restoration: adhese only ?
CEMENTATION PROCEDURE:
1. With sandblasting treatment:
‒ Sandblasting with 25-50µm alumina 0.15MPa/1.5bar is recommended
‒ Blow the restoration with an oil-free air syringe or clean with an ultrasonic cleaner and dry
‒ Clean with alcohol to remove oil residue
‒ Treat the surface with a silane coupling agent such as CERAMIC PRIMER II (GC)
‒ Cement with a conventional resin cement (luting composite) and bonding agent
NOTE: Prior to using CERAMIC PRIMER II (GC) or resin cement, refer to the respective manufacturer’s Instructions for Use of the manufacturer
2. Without sandblasting technique:
‒ Treat with hydrofluoric acid (5%) for 60 seconds
‒ Wash with water spray or an ultrasonic cleaner and dry
‒ Clean with alcohol to remove oil residue
‒ Treat the surface with a silane coupling agent such as CERAMIC PRIMER II (GC)
‒ Cement with a conventional resin cement and bonding agent
