Challenge yourself with Anteriors
Afternoon everyone,
It's just amazing what we get to do everyday and the technology we can do it with. The excitement level from patients to my team just keeps getting better and better. I wanted to post these 2 cases because the "dreaded single central" are the most challenging cases to me. And somehow we have had 2 this week.Â
People always ask, "what material I should use for this case....". And as all of us know it varies. So just wanted to show 2 different materials that you can use on a day to day basis. I will have to say that I could not do this type of anterior without a very passionate team member. My assistant is very talented with staining a glazing and is an invaluable asset to my cosmetic work.
Case 1: 61 year old male that had a 30 year old PFM that I have been asking at every hygiene check if he wanted to replace. Every year, no not this year, not bothering me. Well this year was the year. He decided to replace it. Used biojaw to get good starting point and then refined post mill. Was very happy just from the initial try in with no stain or glaze. This case was Vita Triluxe, 1 fire.
Case 2: 66 year old female with #8 having RCT a while ago and had 2 large composite fillings on the lingual. Decision was made for full coverage since they were leaking and a redo filling was not a great option. Discussed doing some ortho or involving more teeth, but patient decided on just 1. So had lengthy discussion of copying existing size and shape. Biocopy was used on this case. Vita Mark 2 with 2 fires (1 stain and 1 glaze). Value may be a little low, but will see in a few weeks after teeth rehydrate.
Tom
Hmmm... well.... to say nice job seems inadequate... But NICE job Tom! I'll go look for my thesaurus now...
Mark
Characterization on both cases is very well done! Great stuff. Thanks for sharing and raising the bar for all of us.
Real nice work! Patients were delighted I'm sure.Â
​On your first case, is the difference in texture due to your glaze, or the anatomy you designed/cut into the Triluxe?
Â
Looks great Tom! Thanks for sharing. Couple of Q's for you if you don't mind:
What do you use for your stains?
Do you do it intra-orally after(or before) first fire or do you go by pre-op photograph?
On 3/22/2016 at 12:14 pm, Kristine Aadland said...Gorgeous- did she use Lustre??? Were the tips helpful at all?
Kris,
Still can't get the technique down for lustre paste. Tips were helpful and have been working on it, just practicing until we get more comfortable.
On 3/22/2016 at 12:59 pm, Sahil Patel said...Real nice work! Patients were delighted I'm sure.Â
​On your first case, is the difference in texture due to your glaze, or the anatomy you designed/cut into the Triluxe?
Â
Sahil,
​The texture is from contouring and putting the texture in with diamond disks before the glaze is applied.
On 3/22/2016 at 1:13 pm, Nassim Missaghian said...Looks great Tom! Thanks for sharing. Couple of Q's for you if you don't mind:
What do you use for your stains?
Do you do it intra-orally after(or before) first fire or do you go by pre-op photograph?
Nassim,
​We used Empress Universal stains. Mixed some colors to get to the shades desired.Â
We stain outside the mouth off of photography. Sometimes will carry the crown to the room and visualize where we want to put the stains. I have heard some people will stain in the mouth then tease it off and put it on a firing peg, I'm not that good yet ;)
Â
Took your challenge ;) Here is my afternoon case... same day photos- but I couldn't resist!
These are e.max HT with e.max stains.I did the contouring and my assistant did the staining. The patient was really excited and after seeing these now wants to do the laterals- thank goodness!
Kris my grits ;). Awesome job. How thin were the facials? HTs always seem to "grey out" on me and value drops. Only way it seems to be ok if the facial porcelain thickness is thin. Great work as always.
As an aside my assistant wanted to use emax on the second case but ultimately decided to give mark 2 a try. It's nice to have so many options at our disposal now.
TK explained the saying to me. It from a TV series "Alice" I believe ;)
Looking at her pre-op photos I wanted to grey effect. She had so much grey and translucency already in her teeth it's what i was going for. I wasn't super thin though. They were crowns and my minimal thickness setting is pretty high so over 1 mm for sure. We actually use grey a lot as stain too with the blue and did on her case.
HT gets kid of a bad rep but I use it a lot.
On 3/22/2016 at 10:41 am, Mark Stockwell said...Hmmm... well.... to say nice job seems inadequate... But NICE job Tom! I'll go look for my thesaurus now...
Mark
I believe the word you're looking for is "amaze-balls"
Great job Tom!
On 3/22/2016 at 8:01 pm, Karen Lai said...On 3/22/2016 at 10:41 am, Mark Stockwell said...Hmmm... well.... to say nice job seems inadequate... But NICE job Tom! I'll go look for my thesaurus now...
Mark
I believe the word you're looking for is "amaze-balls"
Great job Tom!
Karen-
Funny! I think my edition is too old?
Mark
On 3/22/2016 at 10:03 pm, Jeremy Heldt said...Looks great!  Is this with a chamfer margin design?  Is the facial margin bonded to enamel or dentin?  I haven't done too many anteriors yet and curious to see what people are doing.
Jeremy, here are the 2 preps.
This is the first case. Replaced the old PFM, had mostly an enamel ring around the margin, but reduction already was done. Just smoothed and dropped my facial margin. My prep margins i would say are sloping deep chamfers? hard to describe, not butt margins and not chamfers, but somewhere between. You can prep with a chamfer if you want, just bump your marginal thickness out and then you just have to hand polish back your margin so the mill doesn't chip it.
Case 2 I used the prep reduction burs from bob winter to get my facial reduction in 3 planes. Same thing, ring of enamel, had to prep slightly deeper to block out the stump. Again, you can see mostly the enamel ring and the sloping away margin.Â
Hope this helps. Start doing anteriors, pick the "you can't make this any worse than what the patient has" cases.
Tom
Tom really nice cases. Â I love the fact that you are getting these results with the good old empress stains. Dentists tend to keep searching for the magic bullet. Â Find a system and master it, which you have obviously done. Â Â That is the key.Â
how do you block out the stump shade especially on a greyed rct tooth?  I replaced a PFM with an unesthetic gingival metal margin with an A3 LT block and the patient is back with a grey crown? how do I retreat this to avoid the grey?
Mike
I like to use pink opaquer for blocking out a dark grey tooth. Cosmedent is my personal choice...
Tom, thanks for sharing. I think it would be great to have a "lab work" workshop in Scottsdale with doctors like you and some of the others who really have the techniques down. I still tend to send this type of case out through Sirona Connect OR I whiten them up first to make matching easier in house.
BRUSH A LITTLE OPAQUE INSIDE THE FACIAL PORTION OF THE CROWN. THIS TECHNIQUE WILL BLOCK OUT A DARKER STUMP SHADE AND RETAIN THE AESTHETIC VALUE OF HT E.MAX.
I don't think it is as simple as brushing on some opaquer. You will have to modify your parameters for spacer and depending on your porcelain thickness it will potentially change inherent properties of your milled block from an HT to an MT or LT and simply not block out your dark stump.
Daniel
Honestly, it's such a thin layer there's no need to adjust the spacer in the parameter settings. I typically use a B1 shade of opaquer to achieve this and it looks beautiful. Yes, obviously this isn't applicable for every case but it does work and it works well.
Beautiful crowns everyone. My question is how long does it take for you to do these custom staining cases?
Hi Loyd,
For 1-2 anterior crowns I schedule 2 hrs. For 3-4 anterior crowns i typically am at the 3 hr mark and for a bigger case of 6-8 crowns I am 5-6 hrs. I do have 2 milling units so that helps me a bit. I like to give myself time to refire if I need it and try not to have crazy hygiene days at the same time.
Hope that helps!
Are you charging a fee commensurate with the care, skill, judgement, and additional time it takes you to deliver such exceptional results?
No. I'm a heavy PPO practice. My Delta fee is $776 (yay for the state of Washington). I have a passion for it though and am happy to be able to do what I love. I tend to do a fair amount of cases too because of it. Don't get me wrong, I do love the referral when someone doesn't have insurance and I bill my UCR. It all balances out in the end for me so I have no complaints!
On 6/19/2016 at 12:57 pm, Loyd Dowd said...Beautiful crowns everyone. My question is how long does it take for you to do these custom staining cases?
Loyd,
​I'm about the same as Kris. If its empress or vita blocks i'm at about 2-3 hours or so. Usually just a single fire if I need to characterize. If it's a harder case, we'll stain and then try in before we glaze in case we have to change anything else. If it's on the long end at 3, i'll still do procedures in between while my assistant is working on characterization.
If it is a bigger case, any more than 3-4 for me, i'll temporize them and bring them back for delivery. No stress is nice, plus gives them time to test drive it and let me know if there are changes. If there are, I bring them in, make adjustments and update the biocopy folder. Until they tell me it looks good, I won't mill the crowns.Â
As far as cost. I charge about $100 more for an anterior tooth than a posterior. I'm a member of 3 ppos and if I can save on the lab bill that helps. It's just more time for me. But I would charge the same if I sent it to a lab. Way I look at it is that I like doing anteriors and in most cases I can match it closer than the lab. And patients appreciate it more which pays off in the long run.
Hope this helps.
Tom
Tom and others who temporize, so do you have Infinident print a model or someone else?...So I just did a 7 unit case and I was so frustrated because I uploaded the case to Infinident and called the case a crown and simply made a note that I just wanted a trimmed model printed.  I have an account with them that I just set up.  Called it "Cascade Dental Lab" since I heard they don't want to make it a practice to work with dentists and not labs.  Anyway, I hadn't gotten the email from them that they accepted the case so I emailed them and spoke to "Duke" and he said he would check on it. Never heard back and obviously no model.  Sent an extra email in there asking again but nothing.  So I had time to design my case on my time and stain and glaze, but I was really wanting to try everything in on models before the patient came in.  Fortunately, I didn't have to do too much to the case, but frustrating nonetheless. Â
Should I have handled this differently, or what should I have done?
Thanks!
Dan
On 6/20/2016 at 11:22 pm, Daniel Wilson said...Tom and others who temporize, so do you have Infinident print a model or someone else?...So I just did a 7 unit case and I was so frustrated because I uploaded the case to Infinident and called the case a crown and simply made a note that I just wanted a trimmed model printed.  I have an account with them that I just set up.  Called it "Cascade Dental Lab" since I heard they don't want to make it a practice to work with dentists and not labs.  Anyway, I hadn't gotten the email from them that they accepted the case so I emailed them and spoke to "Duke" and he said he would check on it. Never heard back and obviously no model.  Sent an extra email in there asking again but nothing.  So I had time to design my case on my time and stain and glaze, but I was really wanting to try everything in on models before the patient came in.  Fortunately, I didn't have to do too much to the case, but frustrating nonetheless. Â
Should I have handled this differently, or what should I have done?
Thanks!
Dan
Dan,
I'll normally prep, image everything I need. Then temporize with the siltect stint from the lab. Image for my biocopy. Then, I'll carry to the model stage and marginate. After that I export the .dxd file and upload that to infinident. I just ordered an inCoris SLS with no articulation since I biocopied and had worked out occlusion in patient's mouth. I never have had to call and talk to anyone, so maybe it's a fluke.  I just did this last week and models got here Monday, so don't know whats going on. I do like to check contacts on the model as well. Sorry for blinding people on this Tuesday, patient wanted white, this is BL2. 
 Tough case, #8/9 were tipped in and #10 was kicked facially. I'll try and dig up before and afters after I deliver.
Tom
6 month follow up with this case. It's just amazing how the tissue responds to these ceramics. Good to see tissue fill in the embrasures. He has a low lip line, so I'm bothered more with the discrepancy than he is.
hope everyone has a great weekend.
Tom
Haha, I am working, just 3 hours ahead of you, will be done at noon. Then off to Pinehurst to play #2, now I'm rubbing that in 
Yeah...you are...I'll send pics tomorrow of the course I'm playing...just think about Rocco and Tiger
Torrey Pines south course? That's a great track. And not expensive at all. I think for locals it's like $50 because its a municipal course. It was when I played it 5-6 years ago. Be sure and focus, views are amazing. Have fun.
I got a walked in emergency patient yesterday ( day after mentoring level 2) with a broken tooth (#10).In order to matched to the neighbor PFMs,I decided to use the E.Max LT for her.
Here are two lower resolution before and after photos.
