First month with Cerec and 23 restorations later….
My Cerec journey began on June 5th when everything was installed at my office. Since then I have completed 23 Cerec restorations. I’ve learned a lot with each restoration. I’ve been waiting for one to be near perfect that I’m really proud of to post on here but none have met that criteria for me yet. I decided to make a collage of them all and post them together, the good, the bad the ugly. The one thing I can say about all of them is the margins were all BEAUTIFUL on the pre-op and post-op x-rays. So as much as I am down on myself for some parts of a lot of these preps in the end clinically they were all as good as or better than what I was getting from the lab as far as fit and margins.
What I learned so far:
-Early I tried to do too many things at once, 1st patient I did a DOL Onlay on #3 and #4 attempted a MODL Onlay on #4, then decided I would try my first crownlay and not do a build up and try to smooth everything and make it flow together. In the end it resulted in overmilling because without doing a build up I had “points” that could only be smoothed out by taking away what little palatal and buccal tooth structure I had left....
-In fact I tried to do the same thing on my next crown and decided I was trying to do too many new things at once while also learning my way around cerec. Decided I was going to stick to my old tool belt, build up and crowns and make them more smooth, rounded, flowing, and high & dry when possible
-I was shocked on my first few preps at the “roughness” of my margins, even before Cerec I would go over my margins with a fine diamond to smooth things out. I use Two Striper Modified Shoulder 018 coarse followed by fine. What surprised me is that I what looks smooth to my eyes looks different on the computer. Some of this is real minor roughness and some of the roughness I’m exaggerating, basically I thought what was glass smooth to my eyes was rough on the computer. All I have done to fix it is to take my fine diamond around a little slower and with a little more pressure, sort of feeling the bur level everything (when possible, patients and clinical situations aren’t always amenable to tinkering and refining, sometimes you just have to go with what you can).
-What bugs me is I still can’t see the difference in the mouth of the smoothness of my margins, I just make sure I make concerted effort to smooth them with purpose with my fine diamond, generally it works out but sometimes I’m still stumped at rough spots that show up after scanning, maybe I need to bump up from 2.5X to 3.5 or 4.5X…….
-I have always heard most dentists under-reduce. I have been using reduction burs the last year. I use a 1.5mm reduction bur through the occlusal groove and 2-3 grooves through the buccal and lingual (classic). I switched over to the meissingers two months ago. What surprised me is how often I am under-reduced even using this method. More often its on the cuspal inclines and I think I wasn’t “tilting” the reduction bur when connecting to the occlusal groove reduction. I still have this fear of pulping a tooth by reducing too much and I still don’t have the stones for the 2mm reduction bur. I have some preps that I feel like are almost 1/3rd the size of the adjacent tooth and think “no way I don’t have enough reduction” and sure enough either I barely have the 1.2mm required for e. max or I just decide I am not re-prepping and rescanning and I will just reduce the opposing. Most of the time its on molars. Which makes wonder how are people doing crownlays on molars? I think its bad luck with case selection, 2nd molars and under-erupted 1st molars, time will tell, moving forward I have been connecting the occlusal groove reduction to the buccal-lingual reductions by laying my 1.6mm diamond cylinder on its side, make sure its completely “sunk” and reducing mesial-distal
-Onalys and inlays are still tough, not as excited about them as I used to be. Feeling like if its not a very conservative onlay, I’d rather do a crown. Part of this is a have very well eductated patient baser. I got some patients jazzed about onlays because of tooth conservation and during the some of the preps wasted too much time trying to stay conservative and woul decide a little late in the prep design game to go full coverage. This would make for some long appointments. This was early on and I’ve developed a better eye for what will be good for an onlay vs a crown. Oh, and cerasmart is awesome!
All in all I did 11 e. max crowns, 3 zirconia crowns, 1 katana crown, 1 zirconia bridge (forgot to screen shot it so I put in the BW) and the rest cerasmart inlays/onlays
I can look at each of these and tell you something I seriously don’t like about each of the preps, some worse than others, either way, here they are... I am registered for level 2 beginning of August, maybe I'll see some of you there
Hi Steven in Gilbert!! (I grew up in Glendale....)
so without enlarging all the screen shots you sent and reading your text, is telling me that you are doing CEREC the way it should be done..You are driven to learn, see results and improve.!!! This is all a process and as you keep margins fantastic, the other things..( fissure, occlusion, contacts, contour AND materials) will guide you to your best result....keep posting and love the process... as it will continually evolve
Thanks, I think I will edit the original post and make the pictures larger, the text is for anyone interested
Steven,
‘I think we all go through what you are describing. Excitement and frustration. It can be a little overwhelming and humbling at first. It will make you a better dentist. It’s hard to put your work out there for others to see, but a great way to improve. This is a great group to help you on your journey. Level 2 is a great start, it was for me.
There is no other site like this one with docs supportive to help you
good luck and keep.posting.
Great post and beautiful work! Documenting your cases is really the best way to keep improving. I have no doubt that you'll be very successful with CEREC and would be surprised if we don't see a mentor badge by your name very soon.
love these kinds of posts. great start to a fun and practice changing journey. I would move up to that 2.0mm reduction bur if you want to be able to use any an all materials. with the 1.5 mm bur, with the occlusal offset setting of -150 or more, you will never get a true 1.5mm in the central groove. I have been using a 2.0mm reduction bur for over a decade. I can say personally I have never pulped out. you always want to be aware but you should not really run into an issue with just .5mm more and you'll have a lot more versatility on the materials you can use. congrats on a great first month
On 6/29/2018 at 11:22 pm, Mark Stockwell said... Now that’s something that deserves more than iPhone look! Mark
I’m happy to post larger versions of any particular prep
On 6/30/2018 at 7:03 am, Richard Rosenblatt said...love these kinds of posts. great start to a fun and practice changing journey. I would move up to that 2.0mm reduction bur if you want to be able to use any an all materials. with the 1.5 mm bur, with the occlusal offset setting of -150 or more, you will never get a true 1.5mm in the central groove. I have been using a 2.0mm reduction bur for over a decade. I can say personally I have never pulped out. you always want to be aware but you should not really run into an issue with just .5mm more and you'll have a lot more versatility on the materials you can use. congrats on a great first month
My assistant and I were thinking the same thing with the 2mm reduction bur, I have them and will give it a shot. I agree it’s limited the materials I can use, which is why all the crowns have been e. Max, a few zirconia, and one Celtra when I had plenty of material thickness. I set up my parameters based on the 4.5 tutorial, I don’t violate minimal thickness requirements and I adhesively bond all glass ceramics with calibra ceram and prime and bond elect. I appreciate the feedback, seriously, and I will post some cases when I get back into the office after next week’s vacation. I’m teeming with more questions for everyone, been trying to hold off until level two....
Welcome to the club. You will find that patients LOVE it just as much as we do if not more and that's what it's all about. Enjoy!
Steven,
Nice job in your first month. I use prep check and the 1.5 mm reduction burs. The prep check helps to see if you reduced enough. Hate finding that out after final imaging. Great job, on lays the first month is hard to do.
Carrie
On 7/1/2018 at 1:21 pm, Carrie Polster said...Steven,
Nice job in your first month. I use prep check and the 1.5 mm reduction burs. The prep check helps to see if you reduced enough. Hate finding that out after final imaging. Great job, on lays the first month is hard to do.
Carrie
Thanks! Can't you only do prep check after you've scanned Upper, lower, and bite in the set axis/set margin screen? Grew up in Randolph, NJ BTW 
Hey Steve. I just saw this post and am very proud to see you how well you're doing with your CEREC since the Exceed program. No doubt you have already become a better clinician with all the things you've mentioned. Keep it up!
On 8/8/2018 at 9:25 am, John Yu said...Hey Steve. I just saw this post and am very proud to see you how well you're doing with your CEREC since the Exceed program. No doubt you have already become a better clinician with all the things you've mentioned. Keep it up!
Thanks John, I learned a lot at level 2 last week as well! Considering making a part 2 to this post as I did 22ish restorations last month and I've come along way. One of the best things is that since getting my cerec June 5th I've only punted one case to the lab, it was a really tough bridge case on a handicapped patient with a path of insertion that could not be milled, I've done 3 other bridges that all went beautifully.
You know, when a new user takes the time to learn, to implement and to perform, the CEREC system is a thing of beauty! Great work!
And thing is Steven, we never stop learning. Still trying to improve after 22 years using CEREC.
Thank you for nice post!
Steven. I’m right there with you. Just finished my 29th Cerec restoration in 45 days since install and initial training. Went to Atlanta and learned a ton in level 1. If you bury a 330 bur in the central fossa and carry it lingual/ buccal and mesio/ distal and then connect it all, you will have 2mm of occlusal clearance everywhere. Courtesy of Dr Ed. Works like a charm. I’ve stuck to single posterior teeth so far. No bridges or anteriors yet. Waiting to get good at molars and premolars first. It’s a BIG learning curve, but fun.
I just f....d up an onlay today. Had to temporize and bring the patient back tomorrow, I hope.
Stupid mistake I made in changing the burs on the mill. Silly things......otherwise it would’ve gone well. We live and learn. Get frustrated and celebrate the victories, when we get them.
Cerec has sparked life into my professional career. I was bored and desilusióned after 30 yrs in practice.
I’m now scared, excited and all of the above. Feeling good about Dentistry again.
Keep up the great work!!!!!
On 8/8/2018 at 4:14 pm, Jose Gallegos said... Steven. I’m right there with you. Just finished my 29th Cerec restoration in 45 days since install and initial training. Went to Atlanta and learned a ton in level 1. If you bury a 330 bur in the central fossa and carry it lingual/ buccal and mesio/ distal and then connect it all, you will have 2mm of occlusal clearance everywhere. Courtesy of Dr Ed. Works like a charm. I’ve stuck to single posterior teeth so far. No bridges or anteriors yet. Waiting to get good at molars and premolars first. It’s a BIG learning curve, but fun. I just f....d up an onlay today. Had to temporize and bring the patient back tomorrow, I hope. Stupid mistake I made in changing the burs on the mill. Silly things......otherwise it would’ve gone well. We live and learn. Get frustrated and celebrate the victories, when we get them. Cerec has sparked life into my professional career. I was bored and desilusióned after 30 yrs in practice. I’m now scared, excited and all of the above. Feeling good about Dentistry again. Keep up the great work!!!!!
Make sure you get your Level 2 Training. It is included in the purchase of the technology.
Going to post some more cases from last month, did 22 Cerec restorations in July with nothing sent to the lab. All the advice I got REALLY HELPED I was way more efficient and preps got a lot better. One of the biggest helps was moving to the 2mm reduction bur. I shoot to be able to use Celtra when I can, using the 2mm reduction bur and my 1.6mm cylinder bur to verify reduction I can hit that 1.7mm reduction pretty easily and repeatedly, and if not it’s a very easy e. Max case.
I found I don’t use my laser very much, only for deep preps wear the gingiva is really in the way. My main retraction method is single 1 or 0 cord followed by traxodent and a comprecap if the margin is subgingival (I try to keep high and dry whenever possible) or there is bleeding.
I am going post some cases, the good and the not so good....
First a few of the good:
Did this case beginning of July, e. Max, patient out the door 2.5ish hours. Luckily I had HD TVs with Netflix so patients just hang out and watch their favorite shows or movies, I have not yet had anyone complain about time, something that continues to surprise me.....
Overall, looking back on these preps and the whole month I would like my shoulders to get a little smaller, may switch the 018 for an 016
Buccal on #18 had a resin with a very deep margin that I deep my best removing and trying to find “solid ground”
Still some sharp spots on the occlusal that I wish were more flowing and would like to narrow up the margins and make them more uniform.
Here’s a Zirconia bridge I did.... over prepped the shoulders in my opinion but the only case I had to punt was a week prior and it was a bridge that couldn’t be milled because of the path of insertion so I think I was trying to avoid that on this one.
Also took 3.5-4 hours...... I got a warning saying the restoration might not fit in the block, it milled but the sprue was super thin and the restoration “fell” off the block as I was removing from the mill and broke. I told the patient and suggested we make a temporary and have him come back but he told me he had the day off and brought a good book. I put a new block in and when I took it out I held a triple folded hand towel underneath to break the fall just in case. I did some infiltration and it came out pretty nice, as good as if not slightly better than his old PFM
This is a case I did on my hygienist, e. Max 1 hour 45 minutes, I am slow on processing e. Max, I had this prepped and ready to scan in 20-25 minutes and scanned designed in 10ish minutes.... I still do a pre-op x-ray and try-in in the purple stage.... I wipe down the restoration with cavicide and rinse with water before bring it back into the lab and I am really thorough about object fix and then after cool down I scrub out the object fix with a tooth brush and water......
i was happy getting a decent prep out relatively quick and this is when I was starting to keep things really high and dry.
Felt like everything could have been a lot smooth, margins and rest of prep
This was a really TOUGH case..... not pretty but it WORKED.... Pre-op situation was tough... #19 had an old PFM crown with an Amalgam core and RCT that had a ton of interproximal decay and needed to gut the thing. I was taking silver out for days, felt Zoolander with the black lung.... Then rebuilding it, managing tissue with the laser, getting a “functional margin” and getting hemostasis... tired thinking about it....
This where I looked at my assistant and said, “Ain’t getting no margin like that from the lab” and from the point forward I live in fear of sending case back out to the lab....
This case is near and dear to my heart. Had a young family member in the chair. She was only 11 with #3 bombed out, I could believe I was not into the nerve. Got all the decay out and really didn’t want to be doing a crown on a 11 year old, so I did my best refining the prep and went with a Cerasmart Onlay.... I love that material, it fits and shines up and blends really nice
I did have a nice chat with the parents about oral hygiene and diet 
It’s fun to hear you sharing your excitement and it is fantastic how fast your going! This is awesome technology and it helps you becoming a better dentist for sure. There are so many things that can go wrong and I am sure I have not encountered all in my 20+ years of Cerec use. With that said it is paramount to seek evidence based education and you will find that in the cerecdoctors course for sure. Secondly if there is a Cerec study club in your area join it. If there is none consider starting one. This is exactly what keeps me going with Cerec! Excitement. Someone take Cerec out of my practice will be the day I retire selling antiques and red wine. (And beer )
Juergen
On 8/11/2018 at 10:52 am, Juergen Langenbach said... It’s fun to hear you sharing your excitement and it is fantastic how fast your going! This is awesome technology and it helps you becoming a better dentist for sure. There are so many things that can go wrong and I am sure I have not encountered all in my 20+ years of Cerec use. With that said it is paramount to seek evidence based education and you will find that in the cerecdoctors course for sure. Secondly if there is a Cerec study club in your area join it. If there is none consider starting one. This is exactly what keeps me going with Cerec! Excitement. Someone take Cerec out of my practice will be the day I retire selling antiques and red wine. (And beer ) Juergen
I am spoiled living only 40 minutes from the Spear Center in Arizona, I have already taken level 2 and have every intention of taking the rest of the courses in Scottsdale.
