Importance of Contours and Texture for Anteriors
I wanted to share my experience from some of these larger cases I have completed recently. First off, Level 4 was a huge help and I cannot give that course enough credit. Sam, Mike, and Mark do a great job updating the content and making sure to cover as much as possible. Everytime I mentor a Level 4 course I pick up something new that I can use when I get back to the office.
I took photos throughout the process, but don't want to overload with too many on this thread. What I did want to point out was how the process of Cerec and milling gets you about 80 % there. The mill likes to mill rounded angles so even with copying the waxup/mockup you will still have some work to do post milling. The models were ordered by exporting the case after margination as a .dxd file. Upload to Infinident and they will send nice solid models as well as trimmed models in about 3-4 days. Cost about $25. They can also send an opposing. Most of these cases I'll rely on the biocopy and never order the opposing.
Tips to make this process flow:
1. Get a good waxup from your lab. Most of the time they will waxup in grey or blue to allow contours to pop. A siltec stint or any putty stint should be made as well.
2. Transfer that to the mouth. I dont like trying to stitch the preps in the mouth to a waxup off a model. Have the patient work out the occlusion and copy that for your biocopy.
3. Any teeth more than 2, I do in 2 visits. Its just too stressful for me. Order a model and work on your own time.
4. Contour and prepolish then crystalize. (obviously if using Emax)
5. Then add characteristics with stains and fire. Finally glaze. If I separate these steps it just helps visualize the outcomes.
Case 1:
Preop Situation. Patient wanted spaces closed and new partials made to allow her to eat. Ortho was declined even though at a young 78 she probably could have done it. Emax A2 MT
Inital: 
Test Drive. She wore these for about 3 weeks. Had to adjust occlusion once.
Initial Milled Models crowns on models from Infinident 
Contouring and Prepolish. Used all burs from Cerec Doctors Kit
After Crystallization 
Stain and Glaze: 
Final Delivery: 
Case 2:
Several old restorations needed attention. Patient's OH is unfortunately not as good, but he is improving. His dexterity is not great due to medical condition. Electric tooth brush hopefully will help him. Posterior teeth were not built out to fill buccal corridor because he did not want to redo his LPD. So had to compromise. Also, had to compromise with him on shade. I did not want to go that white. 
Emax MT A1
Initial:
Lab Work:
Post Ops:
Hopefully this shows how important these post milling steps are. Do yourself a favor and if you really want to start doing some anteriors, check in to Level 4, totally worth your time.
Tom
It's one thing learn and know these things.--- and quite another a lot of times to actually delver it.... NICE work Tom!!
Mark
Nice stuff, very nice contouring, that's the hardest part and the thing that makes them look the best.
Beautiful work! Just to mention another option for those out there that don't have the skills or more importantly, the time to finish a case like this. Cases like this usually take me several hours of "bench" time that I don't have time for during the day. I don't have a lot of desire to work on this stuff after hours either. Since my local lab that I used to send almost everything to isn't nearly as busy as they used to be, I called the owner up and asked him if he would be willing to finish the cases for me after I've milled them. His lab has always done excellent anterior work. We agreed to $40/unit for #7-10 and $50/unit on anything larger, i.e. #4-13, #5-12. On 8-10 unit cases, I simply build the expense into the total case fee....at most, we're talking $500. If his lab does the pre-op waxup of the case, everything drops by $10/unit. I get the case back totally finished, usually within 48-72 hours....which is fine, because I'm not doing these types of cases in single visits anyway.
Now, obviously, not all labs might agree to this kind of deal. What I have found from talking to many smaller lab owners though is that they see/feel the dent CAD dentistry is putting on their businesses and intelligent lab owners are willing to look past the ego issue of "Oh...we didn't make those crowns, we're not going to finish them, etc." and are willing to discuss "case finishing" as a viable source of income. I know there are plenty of dentists out there that love spending their time doing this level of work....I actually enjoy it and find it very satisfying...but I don't find it to be a very efficient or cost effective use of my time at the office during business hours...and I no longer want to come in after hours and do this. I have a staff member that can probably finish cases at these kinds of levels, but again, taking her away from the chair/patients isn't cost effective for the running of the practice.
The labs always ask about "responsibility if something breaks, etc.", I just told him to call me if there's a problem with anything and we'll remill it and get it to them asap. Otherwise, they pick up the case, finish contouring, polishing, staining, glazing and return it ready to seat. Just offering another option to consider.
I think an important point to emphasize is that what separates Tom's cases from something straight out of the mill is how he really sharpens and accentuates the line angles. A really tight closed incisal embrasure like shown in this pic is not easy to do with CEREC.
It is really easy to get the incisal corners of anteriors too rounded and if you use the smooth tool at all on the facial or incisal, it's over.... As Mike, Sam and Flem emphasize, Don't do it! Leave those irregularities and polish post mill.
Thanks guys.
@Robert --- yeah i agree. It does take some time and you have to want to do it. If my lab would do that reduced fee I may consider it. I just find that I always have some time during the day. Contouring and polishing doesn't take that long. Mainly do it in between patients or at lunch. Staining and glazing takes longer just because I have to do it all at once. So Fridays after I drop kids off i'll come in for about an hour or 2 before I can squeeze in 9 holes before I pick the kids up 
@Dan --- 100% agree with you. I'll actually try and build that out and contour by hand because software just wont give those embrasures. Here are some photos showing opening up the embrasures. You can see difference between right side and left side.
before:
after:
red pencil and incisal embrasures, which get larger as you go posteriorly:
finals:
Another great tip I learned from my ceramist is the 3 planes. All anterior teeth have them. Make sure they are defined. Cervical, reflective zone (middle third), and incisal (which gets you translucency). Prepping in 3 planes helps with this as well. You want the light to bounce off the line angles. Hope this helps
Tom
Great work Tom! The extra time you put in for your patients is impressive and takes your cases from good to great.
Just another option:
patients come and sit for hours for anterior composite veneers, so why not do the final contouring/shaping after cementation and in the end intra oral high gloss polishing.
It only takes an hour.
Only feasible in cases without external staining
On 5/25/2017 at 5:42 am, Harry Abachi said... Just another option: patients come and sit for hours for anterior composite veneers, so why not do the final contouring/shaping after cementation and in the end intra oral high gloss polishing. It only takes an hour. Only feasible in cases without external staining
Harry,
That would be doable with other materials. Emax you would do most of the contouring/shaping in the purple state. You would still have to crystalize and then add stain and glaze. Maybe if you were doing Empress Multi or Vita Triluxe and did not have to characterize, I could see that being a possibility. I still think more than 2 teeth too stressful for me, but I know there are several that do these cases in 1 sitting.
Tom
Great work! I guess it's time to redo level 4...2012 is a few decades ago in the dental world.
Tom, I am very impressed. I also like how you took a monolithic block and made it look layered. Great job on the staining and especially the line angles.
I agree with all the positive comments that have been posted. But, to play the devil's advocate here, the cases shown here are not young people. How "natural" does it look to give 60+ year old people 25 year old teeth? Time, erosion, and attrition tend to blunt the well defined line angles and mamelons. Of course, the avoidance of rounded iincisal edge corners here is excellent. But people getting into their 60's tend to loose some of the sharp definition of the mamelons and facial surface texture on the incisors. Could the characterization built into these cases be overdone considering the ages of the patients being treated?
Dr Chuck.
I don't think you crossed any lines in your question. I think it's a Holiday weekend and everyone is enjoying time with family rather than online here. Which begs the question why I'm here... ;)
To answer your question, and it's a valid one, I think the final result should be pt driven. While Nashville isn't Beverly Hills, we have our fair share of AARP citizens with Joan Rivers-type plastic surgery. They seem to love the stretched to the max skin. While I think it's over the top and in no way natural, they love it. Like you, most of my older pt's just want function. They could care less if the shade is off or the incised edges aren't perfectly symmetrical. But I do have those that want the smile/teeth they had in their youth. For those patients, it's nice to have the skills to satisfy their request.
On 5/27/2017 at 1:38 pm, Charles LoGiudice said...Is there any discussion? Or, did I ask a politically incorrect question?
Haha, I don't think it was politically incorrect,
Sorry Chuck, was with the family through the holiday weekend and didn't have a lot of time to write a response. Steve described these cases I did pretty well. I agree that giving a youthful tooth back to someone 60+ years in age is not ideal; however, this is more times than not what patients want. So how I have done these cases in the past is:
1. Get a waxup from a lab including patients age, gender, etc... Also, write up what the patient is going for. I try and have this discussion with photos helping drive the conversation. Waxup comes back , patient approves.
2. Transfer it to the mouth. Even though I'll take the final impression/scan that day as well as my biocopy folder, I still have the patient test drive the case. I tell them after the first week, I want them to be critical and ask family/friends what they think. If something isnt right I'll make adjustments in the mouth, cut out those areas in the biocopy and rescan. So it could be an evolving mockup. When they approve it we are good to go from a shape/contour/function standpoint.
3. The shade/color is the biggest problem in my opinion. Patients always want whiter teeth than they need. We have all wore our sunglasses when we deliver some of these cases even if they are from the lab. I'll show photos, hide certain shade tabs, etc... just to try and direct a patient to the correct color.
Even with all of this, like Steve said, patients want what they want. I look at these cases as their teeth are worn or have failing restorations and I need to restore them (not to a 25 year old tooth hopefully). Patients look at it as I want these teeth (picture of themselves from when they are 25). So I think it's a balancing act, but in the end most of us will give them more esthetically pleasing teeth because that is what they are paying for. Most of this is cosmetic anyway because insurance wont pick any of this up.
Hope that makes sense, but I struggle with this as well.
Tom
