Is it time to embrace digital dentistry?
I often work closely with my ceramicist, Rino Pesa, to create beautiful anterior restorations. Often these case involve significant planning and can involve my Periodontists, Dr. Philip Pack or Dr. Edgard El Charr as well.
I took some after photos of my most recent case , a young lady who at a young age had her root canals performed on her two centrals. When I started treating her 19 years ago she unesthetic crowns on her maxillary centrals and her gingiva always appeared inflammed and swollen. My examination revealed that her crowns were placed too far subgingivally and were causing gingival irritation. We made her two new crowns as well as 4 additional porcelain veneers and these performed well until two years ago, when she fractured her right central incisor.
I sent her to Dr. Pack and he removed her tooth and performed bone grafting as well as a connective tissue graft to plump up her tissue around the extraction site. Unfortunately her cone beam scan showed that she wasn't a great candidate for a single tooth implant replacement since she was still lacking sufficient bone width for a predictable implant restoration. He recommended we try and fabricate a three unit bridge replacement instead.
My patient decided she wanted to also repair her adjacent lateral so that all four anterior incisors would all match. After consulting with Rino we decided to fabricate zirconium crowns with emax porcelain over lays on the buccal and incisal, since this "metal free" configuration would provide the best strength. The linguals of these crown restorations would be mostly zirconium and the connection with the pontic would be stronger as well.
Rino works at Creodental a local laboratory that has made a major investment in scanners and milling machines and he had one of their "designers" scan a study model of my temporary and transfer that as an overlay over a scan of the models made from my final impression. After seeing this proposal I asked them if they could modify it slightly so that the centrals would be the same width ( temporary had one of the centrals slightly wider than the other) and he said yes and made the appropriate modification.
I tried in an unglazed bisque bake in order to check the fit and make sure my patient and I approved the esthetics and then walked her over to Creodent which is only 10 blocks away from my office. When we got there, Rino looked at the case in her mouth and wanted to make some minor modifications, including opening the incisal embrasures a little more to make the case look more natural. When he was done he glazed the case and Darlene delivered the completed box with her case to my office. Unfortunately it was too late in the day for her final cementation so we scheduled this for the following week.
Its been two weeks since her final cementation and I had her return to make any final bite adjustments and to take final photographs. Her gingiva looked great and her inflammation was resolved. I had made the decision not to extend my second preparations as subgingival as was done by her prior dentist . This meant that I left some of the bevelled tooth from her old pfm was left uncovered. I believe that this will not cause a problem and will help correct her violation of biological width problem from before. Her lack of any significant inflammation at her two week post cementation visit seems to confirm the validity of this decision.
My only quandry about this case was, how to cement it. Ultimately I chose to cement it with Fuji cem ( without any resins). I could have bonded the case in or used Fuji plus (a resin modified cement). I didn't choose bonding because the preparations were slightly subgingival and her gingiva was too inflammed for me to get the sort of predictably dry field that I require for my bonded restorations. I did not use Fuji Plus because some of the Lava crowns (Zirconium and porcelain crowns) I cemented with another resin modified cement (Vitremer) had developed problems of delayed sensitivity after a few year in the mouth. When I removed these restorations I found a brown stain around the preparations indicating leakage between the vitremer cement and the teeth.
Both me and my patient were very happy with the result and after almost two years we were extremely relieved to be finished. I probably will suggest my patient have a night guard made to lesson the night time load on her new teeth so that this restoration will have an extended lifespan. Thank you digital dentistry and Creodental! I really like digital dentistry... It's so cool!
from Ask Dr. Spindel - http://lspindelnycdds.blogspot.com/2018/02/is-it-time-to-embrace-digital-dentistry.html - http://lspindelnycdds.blogspot.com/
I took some after photos of my most recent case , a young lady who at a young age had her root canals performed on her two centrals. When I started treating her 19 years ago she unesthetic crowns on her maxillary centrals and her gingiva always appeared inflammed and swollen. My examination revealed that her crowns were placed too far subgingivally and were causing gingival irritation. We made her two new crowns as well as 4 additional porcelain veneers and these performed well until two years ago, when she fractured her right central incisor.
I sent her to Dr. Pack and he removed her tooth and performed bone grafting as well as a connective tissue graft to plump up her tissue around the extraction site. Unfortunately her cone beam scan showed that she wasn't a great candidate for a single tooth implant replacement since she was still lacking sufficient bone width for a predictable implant restoration. He recommended we try and fabricate a three unit bridge replacement instead.
My patient decided she wanted to also repair her adjacent lateral so that all four anterior incisors would all match. After consulting with Rino we decided to fabricate zirconium crowns with emax porcelain over lays on the buccal and incisal, since this "metal free" configuration would provide the best strength. The linguals of these crown restorations would be mostly zirconium and the connection with the pontic would be stronger as well.
Rino works at Creodental a local laboratory that has made a major investment in scanners and milling machines and he had one of their "designers" scan a study model of my temporary and transfer that as an overlay over a scan of the models made from my final impression. After seeing this proposal I asked them if they could modify it slightly so that the centrals would be the same width ( temporary had one of the centrals slightly wider than the other) and he said yes and made the appropriate modification.
I tried in an unglazed bisque bake in order to check the fit and make sure my patient and I approved the esthetics and then walked her over to Creodent which is only 10 blocks away from my office. When we got there, Rino looked at the case in her mouth and wanted to make some minor modifications, including opening the incisal embrasures a little more to make the case look more natural. When he was done he glazed the case and Darlene delivered the completed box with her case to my office. Unfortunately it was too late in the day for her final cementation so we scheduled this for the following week.
Its been two weeks since her final cementation and I had her return to make any final bite adjustments and to take final photographs. Her gingiva looked great and her inflammation was resolved. I had made the decision not to extend my second preparations as subgingival as was done by her prior dentist . This meant that I left some of the bevelled tooth from her old pfm was left uncovered. I believe that this will not cause a problem and will help correct her violation of biological width problem from before. Her lack of any significant inflammation at her two week post cementation visit seems to confirm the validity of this decision.
My only quandry about this case was, how to cement it. Ultimately I chose to cement it with Fuji cem ( without any resins). I could have bonded the case in or used Fuji plus (a resin modified cement). I didn't choose bonding because the preparations were slightly subgingival and her gingiva was too inflammed for me to get the sort of predictably dry field that I require for my bonded restorations. I did not use Fuji Plus because some of the Lava crowns (Zirconium and porcelain crowns) I cemented with another resin modified cement (Vitremer) had developed problems of delayed sensitivity after a few year in the mouth. When I removed these restorations I found a brown stain around the preparations indicating leakage between the vitremer cement and the teeth.
Both me and my patient were very happy with the result and after almost two years we were extremely relieved to be finished. I probably will suggest my patient have a night guard made to lesson the night time load on her new teeth so that this restoration will have an extended lifespan. Thank you digital dentistry and Creodental! I really like digital dentistry... It's so cool!
from Ask Dr. Spindel - http://lspindelnycdds.blogspot.com/2018/02/is-it-time-to-embrace-digital-dentistry.html - http://lspindelnycdds.blogspot.com/
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